Category: Quality Incentive Program (QIP)

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.

CROWNWeb New User Training, QIP

CROWNWeb has announced that their next New User Training session will be held on December 11, 2018.  Find details and register at http://mycrownweb.org/pcw_lems/dec-2018-crownweb-new-user-training/.

The December 2018 CROWNWeb Newsletter is also available, at http://mycrownweb.org/wp-content/uploads/2018/12/December_2018_Newsletter_V1.7-508.pdf.  This issues includes articles on:

  • A Clinical FAQ on Post-Weight Dialysis Assessment date.
  • Scheduled CROWNWeb Clinical Closure Dates; note that your Network may require earlier data entry in some situations.

Announcement of a December 20, 2018 CROWNWeb Town Hall on 2018: A Retrospective Review.  See http://mycrownweb.org/pcw_community_events/crownweb-town-hall-2018-a-retrospective-review/ for details and registration.

CY2019 Changes and Updates to the ESRD QIP & ESRD PPS

On November 1, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2019.  This rule also updates the acute kidney injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI, and finalizes changes to the ESRD Quality Incentive Program (QIP).  Find the summary at https://www.cms.gov/newsroom/fact-sheets/cy19-esrddme-nprm-cms-1691-f-and-dmepos-competitive-bidding-program-temporary-gap-period

ESRD QIP Corner

Don’t miss these important updates:

Facility DFC Data Updated:  The Centers for Medicare & Medicaid Services (CMS) has completed its April refresh of the facility data in Dialysis Facility Compare (DFC). Details about this update can be found at https://data.medicare.gov/data/dialysis-facility-compare.

The newly updated DFC database and current five-star facility ratings can be found at https://www.medicare.gov/dialysisfacilitycompare/.

ESRD QIP Measures Technical Specifications Updated: CMS also recently updated its web page on technical specifications for ESRD QIP Measures to include the CY2018 ESRD PPS Final Rule, and links to Technical Measure Specifications through PY2021.

Find this page at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/061_TechnicalSpecifications.html.

ESRD QIP Rule and NHSN Core Interventions:  The Centers for Disease Control and Prevention (CDC) recently updated its NHSN and CMS ESRD QIP Rule web page and its nine recommend Core Interventions for reducing BSI.

Find these updates at https://www.cdc.gov/nhsn/faqs/dialysis/faq-esrd-qip.html and https://www.cdc.gov/dialysis/prevention-tools/core-interventions.html.

What’s the current status of the ESRD QIP?

The ESRD QIP Current Status webpage can be found here: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/02_CurrentStatus.html

The ESRD QIP establishes incentives for dialysis facilities serving the ESRD population to meet performance standards established by CMS. The quality measures are improved every year via rulemaking. Facility evaluation and payment reductions in a given payment year (PY) are based on performance during a prior year.

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.