QIP/DFC Measures Manual

CMS has published the 2o17 edition of the CMS ESRD Measures Manual, which details how the PY2017 (CY2017) QIP and October 2017 DFC Star Ratings are calculated.  The Manual includes information on the new Kt/V and NHSN QIP measures, TPS calculation, PY2020, and changes to DFC and Star Rating calculations.  Find a copy of the CMS press release, which includes links to the Manual and supporting material, at  https://s3-us-west-2.amazonaws.com/nwrn.org/files/QIP/CMS%2CQIP.061617.pdf .

9/30 NHSN Annual Training

The Dialysis Event training course is now available on the Dialysis Event homepage.  Every NHSN user must complete re-training annually, before September 30, by re-reading the Dialysis Event Protocol at https://www.cdc.gov/nhsn/pdfs/pscmanual/8pscdialysiseventcurrent.pdf , and taking the online training course at https://nhsn.cdc.gov/nhsntraining/courses/2016/C18/ .  To properly identify yourself and get training credit for your facility and yourself, you must enter your First Name, Last Name, email address, 5-digit facility “OrgID,” and Network Number before completing the test.

The email address entered must be the email address associated with your SAMS account.  You can identify the correct email address, and your 5-digit facility OrgID, by:

  • Log in to https://sams.cdc.gov
  • Click “NHSN Reporting” and log in to your facility
  • Click on the username in the top-right corner
  • Copy the email address under “My Info”
  • Copy the 5-digit OrgID

Your facility’s ESRD Network number is “16” for facilities in Washington, Oregon, Idaho, Montana or Alaska, and “18” for facilities in Southern and South-Central California.  For other locations see http://esrdncc.org/en/ESRD-network-map/ .

3/31 NHSN QIP Deadline

To meet the CMS ESRD QIP NHSN reporting requirements for Payment Year 2018, outpatient hemodialysis clinics must by March 31, 2017 submit and correct their fourth quarter 2016 Dialysis Event data for October 1 through December 31, 2016.  New or revised fourth quarter data entered into NHSN after March 31 will not be sent to CMS.   Find more information at https://www.cdc.gov/nhsn/dialysis/event/index.html and https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/index.html .

NHSN Annual Training

To fulfill the annual NHSN training requirement, at least one NHSN user at each facility must read the  Dialysis Event Protocol at https://www.cdc.gov/nhsn/pdfs/pscmanual/8pscdialysiseventcurrent.pdf and take the online Dialysis Event Surveillance Training at https://nhsn.cdc.gov/nhsntraining/courses/2016/C18/ before September 30, 2017.   By completing the annual training and passing the post-test, individuals earn 1.5 CME/ 1.3 CNE/ 0.1 CEUs.

CW/NHSN Validation: AST

Facilities need to be aware that Allegheny Science & Technology (AST) is under contract with CMS to validate the accuracy of CROWNWeb and NHSN data.  AST has a data use agreement in place with CMS to request and receive patient records from dialysis facilities for this purpose.  The project is described in the PY2017 final rule, which can be found at  https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/05_LawsandRegs.html .

NW Network Council Call Recordings

A recording of the January 9, 2017 Network Council Call has been placed on the Northwest Renal Network website, along with a pdf of the slides from the webinar.  The call described the current Network contract structure and obligations, with emphasis on this year’s Quality Improvement Activities and CROWNWeb requirements and protocols.  Find the recording at https://healthinsight.adobeconnect.com/p6sn4hjkmow/?proto=true and the slides at https://s3-us-west-2.amazonaws.com/nwrn.org/files/qia/2017/2017NW16NetworkCouncilPresentationFinal.pdf .