Category: All Networks

Review Your Facility Data By August 23, 2018

The PY2019 Preview Period for the ESRD QIP will begin on July 23, 2018, and end on August 23, 2018. The Preview Period provides an important opportunity for each facility to review and ask questions about its ESRD QIP scores and any potential payment reductions that may result. During the Preview Period, facilities will be able to access a Performance Score Report (PSR) to learn about how their estimated Total Performance Scores were calculated. CMS updated this year’s Preview PSR to provide more-streamlined reporting of facility performance.
On July 11, 2018 CMS will present a webinar on the PY2019 Preview Period to discuss how to access, review, and submit clarification questions and/or a formal inquiry about a facility’s estimated scores before the close of the Preview Period. Find details and register at https://register.gotowebinar.com/register/4774560365192234755.
In preparation for the PY 2019 Preview Period, CMS encourages all facilities to review and update their authorized users in accordance with the updated password requirements for Enterprise Identity Management (EIDM) accounts as applied to ESRD Quality Reporting System (EQRS); see
http://mycrownweb.org/2017/06/new-eidem-password-requirements/. Each facility also must designate a point of contact (POC) in EQRS; facilities without a POC will not be able to access their Preview PSRs, nor will they be able to submit clarification questions or a formal inquiry. If your facility has not established authorized users and a POC, CMS encourages you to do so as soon as possible.
For more information and tools, visit the QualityNet ESRD QIP Resources page athttps://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid=1228776130548.
Contact the QualityNet Help Desk with your questions or concerns about use of the ESRD QIP system at qnetsupport-esrd@hcqis.org, or 866-288-8912. Monday-Friday between 5 am and 5 pm PDT.

Extraordinary Circumstances Exception

A facility can request an exception or extension (if applicable) to various quality reporting requirements due to extraordinary circumstances beyond the control of the facility. Such circumstances may include (but are not limited to) natural disasters (such as a severe hurricane or flood), systemic problems with CMS data collection systems that directly affected the ability of facilities to submit data, or extreme circumstances preventing facilities from electronic clinical quality measure (eCQM) or electronic health record (EHR)-based reporting (e.g., extraordinary infrastructure challenges or vendor issues outside of the facility’s control). This also includes temporary closure of the facility. To request an exception or extension, facility administration must complete and submit the “ECE request form”, found here, to the ESRD QIP mailbox at ESRDQIP@cms.hhs.gov. In order for a facility to prevent loss of points under QIP this form must be submitted within 90 calendar days of the extraordinary circumstance following the end of the last reporting period.

Updating Notifications and Accretions in CROWNWeb

Notifications and Accretions must be updated monthly in CROWNWeb. The definitions for these records are:

Notification—a discrepancy in patient data between what CMS and the Social Security Administration (CMS/SSA) database has on record and what exists in CROWNWeb.

Accretion—a record that exists in a CMS/SSA database and believed to be ESRD, but has not been admitted into CROWNWeb as a patient. (An accretion may also occur for existing patients in CROWNWeb whose key identifiers are missing or incorrect.)

All corrections to the data must be made through CROWNWeb. When updating Notifications and Accretions in CROWNWeb:

  • All facilities (including batch submitting organizations) are responsible for correcting and maintaining their own data.
  •  New notifications and accretions should be resolved within 15 days and those that are under investigation are to be resolved within 30 days.
  • The Network is responsible for the oversight of notifications and accretions and will keep facilities informed as these issues arise for correction.
For a complete tutorial, please click here.

Considering the Best Practice of Patient Involvement in Quality Improvement

Ensuring patient involvement in every aspect of healthcare is paramount to positive health outcomes and is a best practice for improvement processes. According to the article, “Patient involvement in quality management: rationale and current status”, through involvement in their care, patients served as catalysts for broad change in the attitudes of staff by providing a motivation for wider organizational changes. These patients were able to adopt different roles across projects where they shared their experiences, helped to identify improvement priorities and developed potential solutions with the staff that had cared for them.
Click here to read more on best practices for involving patients in quality improvement.

Education: A Critical Factor in Understanding De-escalation Techniques

Health care workers have an increased risk of workplace violence compared with workers in private industry, with nurses as the most common victims, and patients as the most common perpetrators, according to an article “Aggression Management Education for Acute Care Nurses: What’s the Evidence?” Risk factors include influences such as ongoing aggressive behaviors, psychiatric disorders, substance abuse, stress/frustration/anxiety, a sense of powerlessness, perceptions that violence is tolerated, inadequate security, long wait times, and lack of awareness. The article offers great tips on how education about aggression management was successful in building confidence in areas such as situational awareness, de-escalation practices and early intervention.
Click here to learn more about de-escalation techniques as presented by Margo Halm, RN, PhD, NEA-BC in the article “Aggression Management Education for Acute Care Nurses: What’s the Evidence?” and contact your Network whenever you need further guidance on managing a difficult patient situation.

Reducing Catheter Rates By Preserving Vascular Access

Reducing facility vascular access rates has been a priority for CMS for many years. With proper and ongoing staff and patient education, patients are able to maintain healthy AV fistulas or grafts. Regular performance of the look, listen, feel check allows early detection of problems andimplementation of appropriate interventions to protect the access . The Look, Listen and Feel technique is a quick and effective way to assess a patient’s access prior to cannulation. This method can be taught to patients so that they can assess their own access on non-dialysis days. This is a simple method of monitoring that does not require any special equipment and can potential save a patient’s access. Photo source: ESRD National Coordinating Center.
For more information, click on the links below:

Understanding the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)

CMS implemented the ESRD QIP in 2012 to promote patient health by providing a financial incentive (pay for performance) for renal dialysis facilities to deliver high quality patient care. Measurements for the 2018 calendar year, which will be reflected in the 2020 payment year, are separated into three components: clinical, safety and reporting. Dialysis facilities are required to report quality measurements to CMS. These quality measurements are made available to the public.
Additional Information about the ESRD QIP:

Living Non-Related Transplant and Paired Kidney Exchange

According to the United Network for the Organ Sharing (UNOS) nationwide, more than 120,000 people are on the waiting list for an organ transplant as of May 2018. Many face a lengthy wait for an available organ. To spare an individual patient a long and uncertain wait, relatives, loved ones, friends, and even individuals who wish to remain anonymous may serve as living donors. About 6,000 transplants each year are made possible by living donors. Two types of non-related kidney donation are:
1.  Non-directed donation. With this type of donation the donor does not name the specific person to get the transplant. The match is arranged based on medical compatibility with a patient in need. Some non-directed donors choose never to meet their recipients. In other cases, the donor and recipient may meet at some time, if they both agree, and if the transplant center policy permits it.
2.  Paired kidney exchanges. This type of donation is becoming very common and an exciting option for kidney recipient and donor pairs who are not compatible with each other. Previously, people with kidney failure who had an incompatible donor were not able to benefit from the transplant being offered to them. However, paired kidney exchange programs are having a significant impact on the expanding options of living kidney transplants. Paired exchanges are now allowing transplants to occur between incompatible donor pairs and in a few unique ways.
There are many types of living kidney donations. The Network encourages dialysis facility staff to educate patients and care givers about transplant options and provide resources to help them make informed decisions.
For more information please visit:

CDC Extends Deadline for Submission of NHSN “Agreement to Participate and Consent” form to June 15, 2018

NHSN’s stated purposes have been recently updated with new provisions for sharing data with local and territorial health departments and with the Centers for Medicare & Medicaid Services (CMS). As a result all newly enrolled facilities must accept the Agreement to Participate and Consent upon enrollment, and all currently participating facilities must accept or “re-consent” to the Agreement.
  • Currently enrolled facilities are required to accept the new Agreement to Participate and Consent electronically by June 15, 2018.
  • If a facility fails to re-consent by the deadline, its NHSN functionality will be suspended until the consent form is accepted.
  • Newly enrolled facilities must consent within 60 days of enrolling in NHSN.
  • After submitting enrollment forms, the person(s) listed as the Dialysis Component Primary Contact and the Healthcare Personnel Primary Contact must log in to the enrolled facility in NHSN.
  • On the Dialysis component homepage, the primary contact should review the electronic consent form and then check the ‘Accept’ box and click ‘Submit’.
  • For more information contact NHSN@cdc.gov with “consent form” in the subject line or visit https://www.cdc.gov/nhsn/about-nhsn/faq-agreement-to-participate.html.

CMS Introduces the ESRD QIP Listserv on QualityNet

Effective at the end of April 2018, CMS will distribute program updates and other important communications exclusively via the End-Stage Renal Disease Quality Incentive Program (ESRD QIP) listserv. This listserv will replace current email blasts from the ESRD QIP mailbox.

Signing up is easy! Simply go here to create your ESRD QIP listserv account by selecting the option for the ESRD QIP. CMS will use the online listserv to distribute communications about changes to ESRD QIP policy and process to the ESRD QIP stakeholder community. You will need to create a user account to receive future communications from the listserv.

If you have any additional questions or concerns, please contact the ESRD QIP team using the ESRD QIP Q&A Tool.

Offering Support for Patients Beyond the Dialysis Center

When starting dialysis, patients are often overwhelmed with the adjustment to their new lifestyle. Navigating end stage renal disease, especially for new patients, can become frustrating, and sometimes can lead to patients feeling defeated by their chronic illness. Additionally, patients experience feelings of loneliness or isolation.

According to the American Association of Kidney Patients (AAKP), becoming involved in a support or adjustment group offers patients emotional support, reduces the feelings associated with loneliness, and provides a safe and secure platform to discuss feelings and emotions commonly associated with the diagnosis of renal failure. A patient making the decision to attend a support or adjustment groups signifies the first step towards acceptance and understanding of their diagnosis.

Initiating, implementing, and sustaining a support group can have its challenges. AAKP offers the Community Patient Support Group Guidebook. The resource was created to assist patients, family and caregivers, and dialysis providers with starting patient support or adjustment group in your service area. The AAKP website offers several ideas for session topics and patient education materials. Visit http://www.aakp.org/ for additional information or call (800)749-AAKP.

Shared Decision Making: The Pinnacle of Patient-Centered Care

In 1988, researchers from the Harvard Medical School, on behalf of the Pickler Institute, developed the model known as the Eight Dimensions of Patient-Centered Care. The model challenges clinicians to cultivate a better understanding of a patient’s illness and address their needs. Secondary to knowledge gain, patients are viewed as equals to clinicians when making decisions about their healthcare.

A component of patient-centered care includes the concept of shared decision making or a process where patients work alongside their clinicians to make decisions about their treatments and care plans. Clinical evidence is reviewed to weigh the risks and outcomes associated with the decisions keeping a focus on the patient’s preferences and values. Benefits that come from patients engaging in the shared decision process include understanding their health along with the pros and cons of different options, being better prepared to collaborate with their healthcare team, and most importantly they are more likely to follow through on their decisions. For more information and tools on shared decision making, visit the New England Journal of Medicine at www.nejm.org and the National Learning Consortium at www.healthit.gov.