CMS: Relief from QIP Reporting

On March 22, 2020 CMS announced relief from QIP-related reporting requirements for CROWNWeb and the ESRD QIP.   Find the full CMS press release at https://www.cms.gov/newsroom/press-releases/cms-announces-relief-clinicians-providers-hospitals-and-facilities-participating-quality-reporting.  An excerpt follows:

“CMS will not count data from January 1, 2020 through June 30, 2020 (Q1-Q2) for performance or payment programs.  Data does not need to be submitted to CMS for this time period…  No data reflecting services provided January 1, 2020 through June 30, 2020 will be used in CMS’s calculations for the Medicare quality reporting… programs.  This is being done to reduce the data collection and reporting burden on providers responding to the COVID-19 pandemic.”

CMS published an additional bulletin on March 27, https://www.cms.gov/files/document/guidance-memo-exceptions-and-extensions-quality-reporting-and-value-based-purchasing-programs.pdf, with ESRD information on pp.9-10.  This bulletin clarifies the original and includes new information on NHSN QIP relief, and information on opting out of the relief:

“Dialysis facilities should be aware of the potential subsequent impact to a facility’s total performance score (TPS) when data are excluded from score calculations.  Facilities impacted by COVID-19 may elect to opt out of the CMS granted exception by emailing the request to the ESRD QIP at esrdqip@cms.hhs.gov.  The email must be sent by the dialysis facility’s chief executive officer (CEO) or designee.  We are requesting that a dialysis facility make this request within 90 days of March 22, 2020.  For further assistance regarding the ESRD QIP information contained in this message, please contact the ESRD QIP at esrdqip@cms.hhs.gov.”

NHSN 2020 News and Deadlines

Current NHSN Dialysis Component BugsContrary to the software’s response, Denominator Data is not actually saved after making updates.  CMS analysis reports within NHSN are not functioning as expected.  On February 11, 2020, NHSN reported that “our technical team is working to resolve [these issues] as soon as possible.  We will provide an update shortly.”  Find the NHSN Current Defects List at https://www.cdc.gov/nhsn/releasemgt/index.html.

The 2020 Outpatient Dialysis Center Practices SurveyBeginning February 8, 2020, users with administrative rights will be able to complete and save this survey by using the ‘Save as Complete’ button.  Facilities must complete the Outpatient Dialysis Center Practices Survey by May 1, 2020 in order to be allowed to enter data into the NHSN Dialysis Component.  Completion by February 28 is recommended.  For convenience, a paper version of the 2020 annual survey can be found at https://www.cdc.gov/nhsn/forms/57.500_OutpatientDialysisSurv_BLANK.pdf.  Enter the information online after you log in to NHSN for your facility.

2020 NHSN Data Deadlines for QIP Credit:  To receive QIP credit, NHSN data for your facility must be entered and corrected by the deadlines in the following table.  For QIA purposes, your Network may require earlier due dates.
  • Data for October-December 2019 must be entered and corrected by March 31, 2020.
  • Data for January-March 2020 must be entered and corrected by June 30, 2020.
  • Data for April-June 2020 must be entered and corrected by September 30, 2020.
  • Data for July-September 2020 must be entered and corrected by December 31, 2020.

Before each QIP deadline, to insure proper credit, each facility should:

Paper versions of all NHSN forms can be found under the ‘Data Collection Forms’ section of https://www.cdc.gov/nhsn/dialysis/event/index.html.  For complete NHSN Dialysis Component specifications, see https://www.cdc.gov/nhsn/dialysis/event/index.html.

12/31 NHSN Possible Lost Data

NHSN resolved a system problem this morning, but if you have edited your denominator data between December 7th and December 18th, those changes may have been lost.  Review your data prior to the December 31, 2019 CMS ESRD QIP quarter 3 reporting deadline to ensure accuracy and completeness by using the 3 step guide at  http://www.cdc.gov/nhsn/pdfs/dialysis/3-steps-to-review-de-data-2014.pdf.  If you have any questions, email them to NHSN@cdc.gov with “dialysis” in the subject line.

NHSN will be down for emergency maintenance today for several hours beginning at 10am PST.  Do not submit CDAs via DIRECT until NHSN is back up.

12/18 NHSN Maintenance, Vs 9.4, Newsletter

The NHSN Dialysis Component will be down for “several hours” on December 18, 2019, starting at 6am PST, for scheduled maintenance.

NHSN Version 9.4 was released on December 7, 2019.  It includes many additions and changes, including analysis updates.  Review pages 1 (all Components) and 4-5 (Dialysis Component) of the Version 9.4 Release Notes at https://s3-us-west-2.amazonaws.com/nwrn.org/files/NHSN/NHSN9.4ReleaseNotes.pdf for important details.  The new analysis output options require regeneration of datasets.  Email all questions to the NHSN Helpdesk at NHSN@cdc.gov.

The December 2019 NHSN Newsletter has been published.  It includes no dialysis-specific articles, but there are relevant general articles on pages 14ff covering NHSN Training in 2020 and CDA changes for Version 9.4.  Find it at https://www.cdc.gov/nhsn/pdfs/newsletters/nhsn-nl-dec19-508.pdf.

Slides from the December 4-5 NHSN Dialysis Surveillance Call can be found at https://s3-us-west-2.amazonaws.com/nwrn.org/files/NHSN/NHSNDialysisEventUpdates2020.pdf.  They include sections on AKI, Data Quality Checks, Annual Training, Missing SIRs, Data Review, QIP Updates, and Version 9.4.

12/4+ NHSN Webinar on 2020 Dialysis Component

NHSN will host a one-hour webinar titled NHSN Dialysis Surveillance Call on December 4, 2019, and repeat it on December 5, both at noon PST, that will detail updates to the NHSN Dialysis Component for 2020.  Pre-register for one or the other at the links below:

Use the same links to join the webinars at showtime.  Because Q&A time is limited, NHSN asks that if you have unanswered questions after the webinar, email their helpdesk at nhsn@cdc.gov with “Dialysis” in the subject line, and they will follow up with you directly.

3/26 NHSN News

The NHSN September Newsletter (https://www.cdc.gov/nhsn/pdfs/newsletters/nhsn-nl-sep19-508.pdf) has no dialysis-specific bulletins, but the section for all users includes articles on the online NHSN Educational Roadmaps such as https://www.cdc.gov/nhsn/training/roadmap/dialysis-roadmap.html, and on page 16 important changes coming in January 2020’s NHSN Release 9.4 to the CDA protocols for automating data uploads to NHSN.

The Newsletter also announces that the usual NHSN Patient Safety Annual Training will not take place in 2020 because they are deferring to the 6th International Conference on Healthcare Associated Infections, cohosted by CDC and the Society for Healthcare Epidemiology of America.  This Conference, which is held only every ten years, will take place March 26-30, 2020 in Atlanta GA, with the theme Global Solutions to Antibiotic Resistance in Healthcare.  See https://decennial2020.org/ for more information.

10/16 NW16 CDC/WA DOH NHSN DUA Webinar

The Washington State Department of Health and CDC have signed a Data Use Agreement that allows WA DOH to routinely use NHSN data for surveillance and prevention.  They have invited all Washington healthcare facilities to an October 16, 2019 webinar about this.  Find more information and register at https://cc.readytalk.com/registration/#/?meeting=ain8mnvp5fqg&campaign=osmk7a2j7cjm.