QIP News: PSSRs, NHSN Deadline, Pain Assessment

PSSRs: CMS has announced that PY2019 Performance Score Summary Reports or PSSRs are now available.  The PSSR is a spreadsheet containing the performance values of each facility for PY2019.  It provides information about facility performance on each ESRD QIP measure as well as the Total Performance Score.  Find the PSSRs at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/Downloads/PY2019-Performance-Score-Summary-Report-.XLSX.  It’s a 12+ megabyte file, so it may take several minutes to download and open.

NHSN: CMS has also announced an extension to the NHSN data entry deadline for the ESRD QIP fourth reporting quarter of 2018 (data for October 1 – December 31, 2018) from March 31, 2019 to April 1, 2019.

Assistance regarding PSSRs or the NHSN deadline can be obtained by contacting the ESRD QIP Support Team using the ESRD QIP Q&A Tool at https://cms-ocsq.custhelp.com/app/homeesrdqip/p/960.  For questions or concerns regarding use of the ESRD QIP system, contact the QualityNet Help Desk at qnetsupport-esrd@hcqis.org or 866-288-8912 between 5am and 7pm PT Monday-Friday.

Pain Assessment data submission into CROWNWeb will no longer be required by CMS starting March 1, 2019.  The Pain Assessment screen will remain active for facilities to review previously reported data.  For details see http://mycrownweb.org/2019/02/pain-assessment-submission/.

1/17 CW Town Hall

CROWNWeb has announced the topics for their January 17, 2019 Town Hall meeting.  They encompass completing Calendar Year 2018 CROWNWeb reporting requirements, including requirements and closure dates for ICH CAHPS Attestation, Pain Assessment, Depression Screening, and the CMS-2744 Annual Facility Survey.  Several new EQRS features will also be presented.  Register at http://mycrownweb.org/pcw_community_events/january-2019-town-hall/.

9/10 QIP PY2021-24 Correction

CMS has announced a correction to their bulletin about proposed PY2021-24 QIP performance measure changes, which we forwarded as https://nwrnbulletins.wordpress.com/2018/08/06/9-10-qip-py2021-24/Depression Screening is NOT proposed to be eliminated in PY2021, and Pain Assessment IS proposed to be eliminated in PY2021.  We’ve corrected our earlier bulletin.  Comments on the proposed changes are due by September 10, 2018.

9/10 QIP PY2021-24

CMS has released the proposed ESRD QIP Technical Specifications for PY2021, 2022, and 2024.  Proposed changes include:

  • Elimination of Pain Assessment (NOT Depression Screening as indicated earlier), NHSN Healthcare Personnel Vaccination, Anemia Management, and Serum Phosphorous in PY2021.
  • New measures for Medication Reconciliation Reporting and Existing-Patient Transplant Waitlist for PY2022.
  • A new measure for Incident-Patient Transplant Waitlist in PY2024.
The proposed Technical Specifications can be found at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/061_TechnicalSpecifications.html.  Comments on the proposals are due by September 10, 2018.  For more information see https://nwrnbulletins.wordpress.com/2018/07/11/cy2019-esrd-pps-proposed-rule/.

8/9+ CW & EQRS Training, Resources

EQRS 2.0 will be installed during regular overnight maintenance on August 9, 2018, and training on EQRS 2.0 will be offered on August 9 and repeated on August 10, 2018.  For more information see http://mycrownweb.org/education_/training-calendar/ for August.

The same calendar announces a New User Training on August 14, 2018.

Slides and recordings of CROWNWeb Town Halls can be found at http://mycrownweb.org/events/.  The July 26, 2018 Town Hall included a review of Pain Assessment and Depression Screening.

7/26 CW Town Hall re EQRS

CROWNWeb has announced the topic for their July 26, 2018 Town Hall meeting: The Journey From CROWNWeb to EQRS.  The head of the EQRS program, P. Nicole Crenshaw, will discuss the vision for EQRS, as well as the transition from CROWNWeb, ESRD QIP and REMIS to EQRS.  Additionally, the call will provide an overview of completing the Pain Assessments and Depression Screenings in CROWNWeb.  Register at http://mycrownweb.org/pcw_community_events/crownweb-town-hall-event-the-journey-from-crownweb-to-eqrs/.

9/10 CY2019 ESRD PPS Proposed Rule

CMS has released a proposed rule for the CY2019 ESRD PPS, titled Proposed Updates to Policies and Payment Rates for the ESRD PPS, … QIP; and Payment for Renal Dialysis Services Furnished to Individuals with AKI and a fact sheet summarizing it.  The ellipsis in the title refers to durable medical equipment changes included in the same proposed rule.  Find the fact sheet at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-11.html.

The fact sheet includes summaries of:

  • Removing the Healthcare Personnel Vaccination, Pain Assessment, Anemia Management, and Serum Phosphorus reporting measures from the PY2021 QIP.
  • Restructuring domains and weights in the PY2021 QIP.
  • Expanding NHSN validation in both PY2021 and PY2022.
  • Adding measures for Percentage of Patients Waitlisted and Medication Reconciliation to the PY2022 QIP.
  • Adding a measure on Standardized First Transplant Waitlist Ratio for Incident Patients to the PY2024 QIP.

The proposed rule can be found on the Federal Register at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14986.pdf.  Comments must be received by September 10, 2018.