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.
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.
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.
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.
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 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.
CMS has published an MLN Matters bulletin on Implementation of Changes in the ESRD PPS and Payment for Dialysis Furnished for AKI in ESRD Facilities for CY2019. Find it at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11021.pdf.
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.
- Open the master PDF which contains all the PSCs for all the facilities the user has downloaded
- Select File → Print
- From the Printer drop down, select a PDF Writer
- 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.
- Click Print
- 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
- 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
- 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 email@example.com or (866) 288-8912 Monday through Friday 8 a.m. – 8p.m. ET.
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.
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:firstname.lastname@example.org or 866-288-8912, 5am-5pm PST, M-F.
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:
- Review the NHSN Dialysis Event Protocol at https://www.cdc.gov/nhsn/PDFs/pscManual/8pscDialysisEventcurrent.pdf to ensure all data were correctly reported to NHSN.
- Use 3 Steps to Review Dialysis Event Surveillance Data at https://www.cdc.gov/nhsn/pdfs/dialysis/3-steps-to-review-de-data-2014.pdf.
- Use the How to Create and Read an NHSN Report for CMS ESRD QIP guide at https://www.cdc.gov/nhsn/PDFs/dialysis/CMS-QIP-NHSN-report.pdf to verify your facility has met the minimum CMS reporting requirements.
- Refer to the How to Create and Read an NHSN Report for Bloodstream Infections guide at https://www.cdc.gov/nhsn/PDFs/dialysis/BSI-cheatsheet.pdfto review your facility’s bloodstream infection rates.
Contact the NHSN Helpdesk at email@example.com 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 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:
- The schedule for release of the PY2019 QIP reports and certificates:
- December 14, 2018 – PSRs and PSCs will be available to facility POCs on the ESRD QIP System at https://www.qualitynet.org/. PSCs must be prominently displayed in both English and Spanish within fifteen days of their availability and remain posted throughout the entire 2019 calendar year. Facilities without POCs are directed to call the QualityNet Help Desk at 866-288-8912.
- CMS expects to post the Performance Score Summary Report to DFC in January 2019, and to their Public Reporting & Certificates web page at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/08_ReportandCert.html by December 29, 2018.
- Questions may be directed to the QualityNet ESRD QIP Q&A tool at https://cms-ocsq.custhelp.com/app/homeesrdqip/p/960.
- A summary of the November CROWNWeb Town Hall featuring the Kidney Community Emergency Response Coalition’s (KCER) role in emergency preparedness and disaster response coordination, and their coordination with EQRS and CROWNWeb. Slides of the meeting can be found at http://mycrownweb.org/wp-content/uploads/2018/11/November_Town_Hall_Version_2.3_508-Compliant.pdf. More information on KCER can be found at https://www.kcercoalition.com/.
- 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.