Katrina Russell, RN, CNN - NW16 Board ChairStephanie Hutchinson, MBA - Executive Director

Barbara Dommert-Breckler, RN, BSN, CNN - Quality Improvement DirectorLisa Hall, MSSW, LICSW - Patient Services DirectorLeah Skrien - Information Management DirectorJewel Peterman, RN, BSN - Quality Improvement CoordinatorAshley Thomsen, RN - Quality Improvement Coordinator

Corporate Governing Board:

Network Directors & Staff:

To familiarize attendees with the new Statement of Work for the ESRD Networks, and promote partnership with facilities to improve the quality of care for people who require dialysis or transplantation as a life-sustaining treatment.

Purpose:

The18ESRD Networks

Dialysis Facilities

Transplant Centers

Hemodialysis Patients

2015 2016 2017

206

8

Data from CROWNWeb Annual Report

Network 16 Totals

13,800

214

8

218

8

14,426 14,914

Board of DirectorsChair – Katrina Russell, RN, CNNPurpose: To set policy and direction for the Network and retain oversight responsibility.• Responsible for the performance of the Network in meeting

requirements of the CMS contract• Provides financial oversight• Reviews the Annual Report prior to submission to CMS• Approves contract modification requests• Reviews and approves any recommendations from the MRB for

sanctions

Network Governance

Medical Review BoardChair: John Stivelman, MDAdvisory panel to the Network on the care and appropriate placement of dialysis patients and oversight of Network CMS contracted activities, per statutory requirements (1881© of the Social Security Act)

Composed of at least two patient representatives as well as representatives of the professional disciplines engaged in ESRD Care

Provide input to the National Forum of ESRD Networks’ Medical Advisory Committee

Engage in other activities in the Network to improve ESRD care. (Water Manual)

Network Governance

• Comprised of 15 patients/caregivers, one must be a caregiver/family member

• Meets at least semi-annually

• Tasked to provide input into educational materials, offer a patient perspective in selection of QIAs and the development of interventions

“Nothing about me without me.”

Patient Advisory Council

• Comprised of the Facility Administrator/Clinic Director or designee from every facility

• Network provides Annual Update and Environmental Scan

• Council serves as a springboard to relay critical issues experienced in the dialysis setting to CMS

Network Council

• Fully Staffed• Successfully completed the OY 2 contract• Decreased LTC CVC use by 5%• Reduced BSIs by 40%• Increased Transplant Waitlist: 2.63%• Increased VR referrals: 33.93%• Increased Current VR: 2.38%• Increased Home Training: 5.34%

Three Year Accomplishments

Stephanie Hutchinson, MBA, Executive Director

Patient Services Department• Lisa Hall, MSSW, LICSW, Patient Services Director

Quality Department:• Barbara Dommert-Breckler, RN, BSN, CNN, Quality Improvement (QI) Director • Jewel Peterman, RN, BSN, QI Coordinator• Ashley Thomsen, RN, QI Coordinator

Data Department• Leah Skrien, Information Management Director• Shanna Rodarte, Data Coordinator• David Sobieralski, Data and Project Coordinator

Faye Thibodeaux, Administrative and Project Assistant

Network 16 Staff

• Five-year Contract – Now in fourth Year (OY3)• Four Quality Improvement Activities• Increased focus on Patient Engagement• Collaboration with Stakeholders• CMS now requires more facility participation• Development of National LANs

Contract Overview

Network Quality Improvement Activity Management

• We are going to use a Learning Management System this year for Quality Improvement Activity Management

• Used for Facility Self Reporting• Possible upgrades to include interventions and

facility reports

• Provide technical assistance to facilities that will foster patient/family engagement at the facility level• Patient attendance in QAPI• Have a policy that ensures patient

participation in care planning• Host patient support/adjustment groups

Patient/Family Engagement

• Evaluate and resolve grievances• Address issues identified through data analysis

• Appropriate Access to Care– Decrease involuntary discharges and transfers

(IVDs/IVTs)– Address patients at risk for IVD/IVT and failure to

place– Generate monthly access to dialysis care reports

Patient Experience of Care

In preparation for an emergency, ESRD Network 16 will:

• Encourage dialysis facilities to plan for emergency situations

• Provide technical assistance in the development of emergency plans

• Provide educational materials• Develop an internal Network plan for preparedness and

response

Emergency Preparedness

Notify the Network of changes in facility operations, such as:

– Schedule – Power outage – Water issue– Road access/transportation– Other

• Facility Closure/ Interruption in Service form can be found on the website: https://www.nwrn.org/Emergency-Prep

Facility Reporting Requirements

Support NHSN, eMR/HIE Access, Reduce Rates of BSIs including Reduction of Long-Term Catheters

QIA 1: Patient Safety: Blood Stream Infections

• Complex with multiple subprojects:– Adopt CDC Core Interventions for Dialysis

• Hand Hygiene Audits• Reduce CVCs• Support NHSN

– Increase eMR/HIE access– Participation and spread of best practices via the LAN

• National goal: By 2023, reduce the national rate of blood stream infections in dialysis patients by 50% of the blood stream infections that occurred in 2016

Reducing BSIs

• 50% of facilities Network-wide• Demonstrate 20% relative reduction in semi-annual

pooled mean in group with highest 20% of BSIs• Implement all CDC core interventions with targeted

facilities• Perform root cause analysis with any facility that adopted

all CDC core interventions but did not improve by at least 10%

• Participate in bi-monthly nationwide LAN calls starting January 8

Reduce Rates of BSI

• Identify BSI project facilities with long-term (more than 90 days) CVC use rate above 15%

• Decrease rate by at least 2 percentage points by June 2019 (for example, a 17% baseline rate should decrease to at minimum 15%)

• CROWNWeb data from July 2018 is baseline

Reduce Catheters

• Assist new enrollment and SAMS users

• Quarterly data validation checks (Mar/Jun/Sep/Dec)

• Support completion of Annual Surveillance Training

Support NHSN

Due to the NHSN data validation and project dataneeds, we require facilities to enter NHSN data by theend of the following month.

Example: January data must be entered by Feb 28th

NHSN Dialysis Event Surveillance

• Annual SAMS User competency is required for each facility by June

• Step 1: Read the protocol here: https://www.cdc.gov/nhsn/pdfs/pscmanual/8pscdialysiseventcurrent.pdf

• Step 2: Access the training course here: https://nhsn.cdc.gov/nhsntraining/courses/2016/C18/

• Step 3: Attest your clinic has completed the training (or is exempt) via the email link you will receive via email starting in January.

• Step 4: Optional - Collect your CEUs (course #WB2961) by following the instructions here: https://www.cdc.gov/nhsn/pdfs/dialysis/WB2961-tceo-508.pdf

NHSN Annual Competency

• Electronic Medical Records system (eMR) or Health Information Exchange (HIE)

• At least 20% of the project participants

• Access to your patients’ hospitalization records prior to their return from the hospital

• New requirement: “…documentation from the facility that use of the HIE or other evidence-based highly effective information transfer system is successful. This may include policy and procedure or less formal evidence of a system. The facility shall also demonstrate the effectiveness of the system for obtaining information regarding hospitalization in QAPI.”

eMR/HIE Access

NCC BSI LAN Call Schedule

Bloodstream Infection (BSI) QIA LAN

Date (First Tuesdays) Time

Jan. 8, 2019 Noon-1:00pm PTMar. 5, 2019 Noon-1:00pm PTMay 7, 2019 Noon-1:00pm PTJuly 2, 2019 Noon-1:00pm PTSept. 3, 2019 Noon-1:00pm PTNov. 5, 2019 Noon-1:00pm PT

• National goal: by 2023 increase the percentage of ESRD patients on the transplant waitlist to 30% from the 2016 national average of 18.5%

• Include at least 30% of dialysis facilities within Network service area

• Demonstrate a 2 percentage point improvement in the natural trend of the Network of patients on the transplant waitlist

QIA 2: Improve Transplant Coordination

• Each project facility must track and report to CMS the number of patients in each of six steps each month:1. Patient interest in transplant2. Referral call to transplant center3. First visit to transplant center4. Transplant center work-up5. Successful transplant candidate6. On waiting list or evaluate potential living donor

• LDOs FKC/DVA/DCI are contracted to batch step data to the NCC. Patient level detail needed

QIA 2: Improve Transplant Coordination

NCC Transplant LAN Call Schedule

T r a n s p la n t Q I A L A N

D a t e ( T h i r d T u e s d a y s ) T i m e

J a n . 2 2 , 2 0 1 9 N o o n -1 :0 0 p m P T

M a r. 1 9 , 2 0 1 9 N o o n -1 :0 0 p m P T

M a y 2 1 , 2 0 1 9 N o o n -1 :0 0 p m P T

J u ly 1 6 , 2 0 1 9 N o o n -1 :0 0 p m P T

S e p t . 1 7 , 2 0 1 9 N o o n -1 :0 0 p m P T

N o v . 1 9 , 2 0 1 9 N o o n -1 :0 0 p m P T

• National goal: by 2023 increase the percentage of ESRD patients dialyzing at home to 16% from the 2016 national average of 12%

• 30% of facilities within the Network service area

• Demonstrate a 2 percentage point increase in the natural trend of patients that start a home modality by July 31

QIA 3: Promote Appropriate Home Dialysis

Each project facility must track and report to the Network the number of patients in each of seven steps each month. 1. Patient interest in home dialysis (after assisting the patient to

determine modality options that fit the patient’s lifestyle)2. Educational session about home modality3. Patient suitability for home modality determined by a nephrologist

with expertise in home dialysis therapy4. Assessment for appropriate access placement5. Placement of appropriate access6. Patient accepted for home modality training7. Patient begins home modality training

QIA 3: Promote Appropriate Home Dialysis

NCC Home LAN Call Schedule

H o m e M o d a l i t y Q I A L A N

D a t e (S e c o n d T u e s d a y s ) T i m e

J a n . 1 5 , 2 0 1 9 N o o n -1 :0 0 p m P T

M a r. 1 2 , 2 0 1 9 N o o n -1 :0 0 p m P T

M a y 1 4 , 2 0 1 9 N o o n -1 :0 0 p m P T

J u ly 9 , 2 0 1 9 N o o n -1 :0 0 p m P T

S e p t . 1 0 , 2 0 1 9 N o o n -1 :0 0 p m P T

N o v . 1 2 , 2 0 1 9 N o o n -1 :0 0 p m P T

1. Improve Dialysis Care Coordination with a Focus on Reducing Hospital Utilization

2. Positively Impact the Quality of Life of the ESRD Patient with a Focus on Mental Health

3. Support Gainful Employment of ESRD Patients4. Positively Impact the Quality of Life of the ESRD

Patient with a Focus on Pain Management

QIA 4: Population-Focused Pilot QIAs (PHFPQs) Topic Detail

• Demonstrate a 10% point increase in referrals to the Employment Network or Vocation Rehabilitation and 5% point improvement in the number of patients receiving these services by September 30 in 10% of the Network facilities.

• Address disparity in care– Age– Ethnicity– Facility Location (Urban vs. Rural)– Gender– Race

QIA 4: Support Gainful Employment of ESRD Patients

Facility Notification for participation on projects will be sent out:

Week of December 26, 2018

Population Health will have a later notification of the second

week in January.

• Facility compliance with QIP procedures• Download and post Performance Score Certificate: coming

soon

• Master Account Holder (MAH) Passwords (reset 12/13/18) were distributed to MAH and/or Facility Administrator on file

ESRD Quality Incentive Program (QIP)

2744 Annual Facility Survey Schedule: All Network 16 Facilities need to ensure accuracy of Calendar Year (CY) data in CROWNWeb• January 1, 2019: Facilities can begin generating their Annual Facility Survey

(CMS-2744) in CROWNWeb for the Calendar Year 2018 and begin review and data cleanup

• January 15: All “Cleanup Reports” are resolved, nothing left to fix• February 1: All facilities generate and save CY 2018 CMS-2744• February: 2744 Individual Appointments for ESRD NW16

https://booknow.appointment-plus.com/9qg68xdg/• March 31: Final Due Date for submittal to the ESRD Network for approval

2744 Instructions: https://www.nwrn.org/providers-and-professional-staff/im/crownweb.html?id=87

CMS-2744 (Annual Facility Survey)

• EQRS: – Facility Dashboard

• Dashboard does not always show accurate 2728 Info• Report any technical issues to QualityNet Help Desk 1-866-288-8912

– Facilities Module Migrated

• CROWNWeb Data Management Guidelines:http://mycrownweb.org/assets/crownweb-dm/CROWNWeb_Data_Management_Guidelines_FINAL.pdf

– Page 52 has Task List for Facility Users (Tier 1) along with due dates– PART due by 5th working day of each month

• CROWNWeb Resources: https://www.nwrn.org/providers-and-professional-staff/im/crownweb.html

• Email Questions to Data@nw16.esrd.net (no PHI/PII) • Appointments for one-on-one support https://booknow.appointment-

plus.com/9qg68xdg/

CROWNWeb

Identity Management Systems (EIDM and QARM) • EIDM: Enterprise Identity Management System: Used to set up user

account (create login ID and password) to apply for access to QARM and its systems. An EIDM account must be created to access QARM, CROWNWeb and QIP 3.0.

• QARM: QualityNet Authorization Role Management: Apply for access and determine roles in CROWNWeb and QIP 3.0.

EIDM/QARM Registration Resources: • http://mycrownweb.org/education_/eidmqarm-training/• https://www.nwrn.org/providers-and-professional-

staff/im/crownweb.html

Register for CROWNWeb/QIP

CROWNWeb Clinical Updates 2018• Ultrafiltration Rate• Total Number of Dialysis Sessions During Clinical Month

• January 23rd OCT Training: Attestation, Ultrafiltration, and Number of Dialysis Sessions Training Event

http://mycrownweb.org/pcw_lems/january-23rd-attestation-ultrafiltration-and-number-of-dialysis-treatments-training-event/

Common CMS System RolesRole System System Description Related

SystemsLogin ID Looks Like

N H S N A d m i n i s t r a t o r N H S N R e p o r t D i a l y s i s E v e n t s ; S t a f f V a c c i n a t i o n s

E m a i l

E ID M E ID Mh t t p : //P o r t a l . C M S . g o v

C r e a t e a c c o u n t (i n c l u d i n g s e t t i n g u p u s e r ID a n d p a s s w o r d ) t o a c c e s s Q A R M

Q A R MC R O W N W e b Q IP 3 . 0

U s e r c h o o s e s d u r i n g r e g i s t r a t i o n

Q A R M- O r g S e c u r i t y O f f i c i a l

Q A R Mw w w . q u a l i t y n e t . o r g

A p p r o v e , D i s a b l e a n d E d i t Q IM S U s e r A c c o u n t s

E ID MC R O W N W e b Q IP 3 . 0

U s e r c h o o s e s d u r i n g E ID M r e g i s t r a t i o n

C R O W N W e b - F a c i l i t y

A d m i n i s t r a t o r - F a c i l i t y E d i t o r a n d /o r - F a c i l i t y V i e w e r

Q A R M C R O W N W e bw w w . q u a l i t y n e t . o r g

C M S D a t a S y s t e m f o r F a c i l i t y , P a t i e n t a n d C l i n i c a l D a t a

E ID MQ A R M

U s e r c h o o s e s d u r i n g E ID M r e g i s t r a t i o n

Q IP 3 . 0- P o i n t o f C o n t a c t - F a c i l i t y V i e w e r

Q A R M Q IP 3 . 0w w w . q u a l i t y n e t . o r g

V i e w , D o w n l o a d a n d C o m m e n t o n P S R s a n d P S C s

E ID MQ A R M

U s e r c h o o s e s d u r i n g E ID M r e g i s t r a t i o n

D i a l y s i s D a t a . o r g M a s t e r A c c o u n t H o l d e r

w w w . d i a l y s i s d a t a . o r g E n a b l e /D i s a b l e A c c o u n t s ; A d d /R e m o v eP e r m i s s i o n s

C C N

D i a l y s i s D a t a . o r g R e g u l a r U s e r

w w w . d i a l y s i s d a t a . o r g V i e w /E d i t /C o m m e n t o n D F R a n d Q D F C

E m a i l

• All facility staff is responsible for preventing security violations and protecting patient data

• PHI (Protected Health Information) and PII (Personally Identifiable Information) can NEVER be sent over email. – Includes SSN, Patient name or initials, birthdate, etc.

• All security violations are reported to CMS

Security

Environmental Scan

ESRD Network Bulletin

• Sign up for our ESRD Network blog posts at https://nwrnbulletins.wordpress.com/ and

click on the Follow button in the lower right-hand corner.

Bulletin Includes:

• Educational opportunities• Patient-health events• QIP Rules • DFR/DFC release dates• Approaching facility deadlines

We look forward to partnering with you in the new year.

Questions?

SHutchinson@nw16.esrd.netBBreckler@nw16.esrd.net

LHall@nw16.esrd.netLSkrien@nw16.esrd.net

Athomsen@nw16.esrd.net

Network 16 Office: 206-923-0714