Category: Quality Incentive Program (QIP)

New ESRD Quality Incentive Program (QIP) Instructions

On June 1, 2020, the Centers for Medicare & Medicaid Services (CMS) will start the next chapter of its ESRD Quality Reporting System (EQRS) modernization efforts by implementing the first phase of a two-part ESRD Quality Incentive Program (ESRD QIP) User Interface (UI) rollout, in support of the ESRD QIP Payment Year (PY) 2021 Preview Period.

The purpose of this email is to provide guidance related to the June 1, 2020 ESRD QIP UI release. It summarizes the purpose and benefits of the ESRD QIP UI implementation into EQRS, outlines specific tasks that EQRS users who need to access the ESRD QIP UI must complete at this time, and details how users can access available training resources. 

Purpose and Benefits of ESRD QIP UI Implementation into EQRS:

Incorporating the ESRD QIP UI into the EQRS system supports CMS’s efforts to consolidate the functionalities of the CROWNWeb, ESRD QIP, and Renal Management Information System (REMIS) applications into a single system. Users can now use one account to access multiple CMS EQRS business needs via a single platform – the EQRS Global Application.

This rollout of the ESRD QIP UI into EQRS is the first significant change to the ESRD QIP procedures since the inception of the program. The updates to the ESRD QIP UI will improve overall user experience and reduce burden. Phase 1 of the rollout consists of a new role request process and user interface with enhanced navigation features. Fictitious data will be visible in this first release for illustrative purposes only. Phase 2 will be released when the ESRD QIP PY 2021 Preview Period starts in mid-July 2020. Phase 2 will include facilities’ actual PY 2021 data, as well as consist of a streamlined communication and inquiry submission process.

What You Need to Do at This Time:

First, you should check with your organization to confirm if you need an ESRD QIP UI role as a Facility Point of Contact to submit inquiries and access reports, or as a Facility Viewer to see previously submitted inquiries as well as access reports within the ESRD QIP UI.

The June 1, 2020 implementation supports the PY 2021 Preview Period, which is scheduled to start mid-July 2020. This rollout provides users with early access to the ESRD QIP UI to allow them to verify and manage their roles and become familiar with the new UI prior to the start of the PY 2021 Preview Period.

Between June 1, 2020 and mid-July 2020, you should:

NOTE: Roles maintained in the previous ESRD QIP system were automatically migrated into EQRS. Existing roles can be updated, and new users can request access.

  •     Verify that your roles and organizations were migrated over correctly, update an organization’s role, or submit a new ESRD QIP role request.
  •     Click the QIP Scores link in the menu.
  •     Navigate through the ESRD QIP UI to ensure that you are able to access the screens.

IMPORTANT NOTE: Scores and measure feedback shown in the ESRD QIP UI between June 1, 2020 and mid-July 2020 ARE FOR THE PURPOSES OF ILLUSTRATION ONLY – USING FICTITIOUS DATA. THIS DOES NOT REFLECT FACILITIES’ PY 2021 PREVIEW PERIOD SCORES.

  •     Attend ESRD QIP UI Training and PY 2021 Preview Period webinar events.
  •     Maintain system access and log in to the ESRD QIP UI at the start of the PY 2021 Preview Period to access reports and submit necessary inquiries.

Training Materials and Assistance:

Users who still need to complete the HARP account registration process or needs step-by-step instructions on how to request roles within the EQRS system can review training videos, Quick Start Guides, Frequently Asked Questions, and additional materials via MyCROWNWeb.org at https://mycrownweb.org/harp-training/.  

ESRD QIP UI Training and PY 2021 Preview Period webinar events will be provided prior to the start of the PY 2021 Preview Period. Event registration details will be sent via email and posted on www.MyCROWNWeb.org. Sign up for the EQRS Mailing List via www.MyCROWNWeb.org to receive updates regarding upcoming events.

Should you need assistance with accessing EQRS or HARP account or roles, contact the QualityNet Service Desk at Email: qnetsupport-esrd@hcqis.org, phone: 1-866-288-8912, or TRS: 711. Please DO NOT contact the QualityNet Service Desk regarding the FICTITIOUS ESRD QIP scores and measures in the ESRD QIP UI.

Should you need assistance with navigating through the ESRD QIP UI, contact the ESRD Network for your area https://esrdncc.org/en/ESRD-network-map/ and ask for the Data Manager.

ESRD QIP Call: Audio Recording and Transcript

An audio recording and transcript are available for the August 20 Medicare Learning Network call on the End Stage Renal Disease (ESRD) Quality Incentive Program (QIP): CY 2020 ESRD PPS (Prospective Payment System) Proposed Rule Call. Learn about the legislative framework, the proposed rule, and methods for reviewing and commenting on the rule.

REMINDER: Register for ESRD QIP Training July 11, 2019

Thursday, July 11, 2019 at 2:00 PM ET is the first of two ESRD QIP training sessions. Each of these informative 1-hour courses will cover the information needed to begin using the ESRD QIP System. A second session will be held on Monday, July 22, 2019 at 2:00 PM ET. During these sessions, the CROWNWeb Outreach, Communication, and Training (OCT) Team will provide the basics of how to use the ESRD QIP system, including how to effectively submit a clarification question and a formal inquiry, if needed, prior to the end of the preview period.

To join the online event, click on the dates above to register.  Note, both training sessions will contain the same information, users only need to attend one event.

 

 

Join CMS for a Public Webinar on Quality Measurement

CMS is pleased to invite the public to attend its upcoming webinar titled Measuring Quality to Improve Quality: Strengths and Challenges of Clinical Quality Measurement. The webinar will provide an engaging and informative overview of key concepts that go into its quality measures. Additionally, the presentation will review current CMS quality measures, explain how they are used, and how they fit into CMS’s quality goals, including the Meaningful Measures initiative.

The webinar will be offered twice in June, on Tuesday, June 25th, from 2:00-3:00pm EST (Register here) and Thursday, June 27th, from 2:00-3:00pm EST (Register here). Please register in advance if you can attend as space will be limited. CMS requests that interested individuals only register for the event they’re able to attend.  CMS looks forward to participant questions!

For questions, please contact MMSSupport@battelle.org.

NHSN Training

Required Annual Training: The Dialysis Event Module annual training has been updated and moved to a new platform called CDC TRAIN. Self-paced training and post-assessment will remain the same as the previous version, but the CDC TRAIN platform requires you to register with the site, and allows you to save your training certificates after completion. NHSN recommends that all users take this training, but at least one user per facility is required to take and pass this training annually. Find the training course and instruction guide at https://www.cdc.gov/nhsn/dialysis/event/index.html. Email NHSN@cdc.gov with “Dialysis” in the subject line with any questions.

Training Needs Assessment: In taking the NHSN Dialysis Event Module Training Needs Assessment, some users experienced a system error which only permitted them to complete the Demographics section of the survey. If you experienced this, please retake the Assessment, at https://www.surveymonkey.com/r/DialysisEventTNA. NHSN apologizes for the inconvenience and truly values your input. If you have not taken the Assessment yet, please do, to help NHSN better understand training needs for the Dialysis Event Module. The Assessment will remain open until May 31, 2019.

CROWNWeb Pain Assessment Submission

Starting March 1, 2019, the Centers for Medicare and Medicaid Services (CMS) will no longer require facilities to submit Pain Assessment data into CROWNWeb. The Pain Assessment screen will remain active for facilities to review previously reported data in the system.

Additionally, to comply with the ESRD Quality Incentive Program, facilities that meet the requirements for Pain Assessment should continue to enter data for the current open period (July 1, 2018 – December 31, 2018) that will close on February 28, 2019 at 11:59 PM PT.

For information on the requirements and instructions on how to submit data on Pain Assessment in CROWNWeb, please visit the Training videos on the Education page at http://mycrownweb.org/.

NHSN Trainings

NHSN will present four training sessions in March, all at 3-4pm EST. Join any of the four by telephone only at 303.248.0285, Access Code 6393927. To join via computer (including audio):

  • Introduction to the NHSN Dialysis Event Surveillance Protocol: NHSN Dialysis Event Surveillance reporting is required for the CMS ESRD QIP. Complete introduction to the NHSN Dialysis Event reporting requirements and surveillance definitions necessary to complete accurate monthly reporting. Both sessions will be held 3-4pm EST.
    o  March 5, 2019 – pre-register and attend at https://cc.readytalk.com/r/nv7i0guhmafn&eom.
    o  Repeated March 6, 2019 – pre-register and attend at https://cc.readytalk.com/r/is7rdbd8gnym&eom.
  •  Advanced NHSN Dialysis Event Surveillance Reporting and Introduction to NHSN Reports: Applying NHSN Dialysis Event Surveillance definitions via case studies that address common reporting questions. Includes introduction to running and interpreting popular NHSN reports to review your facility’s data, including BSI rates. Both sessions will be held 3-4pm EST.
    o  March 12, 2019 – pre-register and attend at https://cc.readytalk.com/r/avggcki49p0g&eom.
    o  Repeated March 13, 2019 – pre-register and attend at https://cc.readytalk.com/r/yzbfurn4zfm2&eom.

Downloading and Printing of PY2019 Performance Score Certificates

Please be advised that when generating a Performance Score Certificate (PSC) report for PY2019, the CROWNWEB system will generate a report that contains all the PSCs that a user is authorized to view, even if only subset or single facility is selected. While this eliminates the burden of generating a report for each facility, it requires users to split the report into individual PSCs after downloading the combined file. NOTE: If a user has access to only one facility, this issue does not affect them.

This functionality will be adjusted for future payment years, but for the current payment year (PY2019) please employ the two below workarounds to print individual facility PSCs:

Option 1: Use PDF Print option or other PDF tools to split out the PSCs for the individual facilities into individual PDF files.

  1. Open the master PDF which contains all the PSCs for all the facilities the user has downloaded
  2. Select File → Print
  3. From the Printer drop down, select a PDF Writer
  4. From the Pages to Print section, click the Pages radio button and enter the page range to be printed for the PSC for the individual facility.
  5. Click Print
  6. When prompted, select the location to save the file from Step 4

Option 2: Submit a help desk ticket to request report bursting for PSCs

  1. User submits a help desk ticket to Product Data Management (PDM) to request a burst report of PSCs for the facilities assigned to their role
  2. This process may take some time since a Change Request (CR) will be required

For additional information or assistance, please contact the QualityNet Help Desk at qnetsupport-esrd@hcqis.org or (866) 288-8912 Monday through Friday 8 a.m. – 8p.m. ET.

Master Account Holder Quarterly DFC/DFR Requirements

Your facility’s Master Account Holder (MAH) Password and User Accounts on DialysisData.org must be re-established in order to retrieve your facility’s DFR and December 2018 QDFC preview file. On December 13, 2018 all MAH passwords were reset and user accounts for https://www.DialysisData.org disabled. Networks are providing new passwords to facility MAHs. Facility MAHs must log in to their master account to re-enable or add facility user accounts and grant permissions prior to the start of the February 1, 2019 QDFC/QDFR Preview Period. MAHs must create a separate user account to be able to view DFRs and QDFC data, as their MAH account only manages user accounts and cannot view data.

Download the Detailed Timeline for 2019 QDFC Reports, Quarterly Updates of the FY2019 QDFR for State Surveyors Report, and FY2020 DFRs, State and Region Profiles – https://dialysisdata.org/sites/default/files/content/FAQs/Timeline_100918.pdf.

An FAQ page is available on https://www.DialysisData.org, accessible without logging in. Facilities having difficulty logging in or that have other questions may use the “Contact Us” form at https://www.DialysisData.org or call 855-764-2885 M-F, 7am-1pm PST.

It is the MAH’s responsibility to update user contact information (including their own), transfer MAH credentials within the facility appropriately, review and enable existing user accounts, and set user-specific permissions. If MAH credentials are passed on within your facility to a new MAH, please notify your Network and update the contact information on https://www.DialysisData.org to reflect a new contact person for the MAH.

PSRs and PSCs Now Available

CMS has released the PY2019 ESRD QIP Final PSRs and PSCs, which are now available on EQRS.

The PY 2019 Final PSR provides information on your facility’s performance during 2017 and any payment reduction that CMS will impose for reimbursement on 2019 claims. The Final PSR reflects any applicable revisions applied to your facility’s performance scores during the review and correction period and may differ from those displayed during the Preview Period.

Each facility is required to download, print, and post both the English and Spanish versions of the PSC in a prominent patient area within fifteen (15) business days of their availability; facilities also must ensure that these documents remain posted throughout 2019.

PY2019 Final PSRs and PSCs will only be available on EQRS until summer of 2019, when the PY2020 Preview Period will begin. We encourage each facility to save an electronic copy of its Final PSR and PSC for reference, reprinting, and reposting throughout the year should the need arise. Facilities that do not save a copy can request an additional copy from the QualityNet Helpdesk (see below), but should expect a delay in receiving it.

For further assistance regarding the information contained in this message, please contact the ESRD QIP Support Team using the ESRD QIP Q&A Tool at https://cms-ocsq.custhelp.com/app/homeesrdqip/p/960. If you have questions or concerns regarding use of the ESRD QIP system, please contact the QualityNet Help Desk at mailto:qnetsupport-esrd@hcqis.org or 866-288-8912, 5am-5pm PST, M-F.

NHSN Data Deadline for PY2020 QIP

NHSN has advised that NHSN data for July 1-September 30, 2018 must be submitted and corrected by December 31, 2018 in order to be applied to PY2020 QIP scores. NHSN recommends:

Contact the NHSN Helpdesk at nhsn@cdc.gov with subject line “Dialysis” if you have any questions.

The NHSN software was updated to Version 9.2 on December 8, 2018, with many additions and changes, including analysis updates. Please carefully review pages 1 and 7-8 of the Version 9.2 release notes at https://s3-us-west-2.amazonaws.com/nwrn.org/files/NHSN/NHSN9.2.pdf for important details about these changes. To use any of the new analysis output options you must first Regenerate Datasets. Send any questions to the NHSN Helpdesk at NHSN@cdc.gov.