February 2018

 
Quick Links
IPRO ESRD Program
Click here to learn more about the IPRO ESRD Networks (1, 2, 6 & 9).
February is National Heart Month 
 
Heart disease can often be prevented by identifying risk factors and making healthy lifestyle choices. Help ESRD patients reduce their risk. Recommend appropriate preventive services, including cardiovascular disease screening tests and intensive behavioral therapy for cardiovascular disease.
 
For More Information:
 
Visit the   Preventive Services website to learn more about Medicare-covered services.

Quality Improvement
Implementation of the CDC CORE Interventions Saves Lives

 
The Centers for Disease Control and Prevention reports infection is the second most common cause of de ath and hospitalization among dialysis patients.  Hemodialysis patients have multiple and frequent exposure to healthcare environments undergoing treatment three times per week with direct access to their bloodstream v ia venipuncture and catheters.  Healthcare expenditures for these infections are staggering. Research has shown tha t the Imple mentation of the CDC core interventions reduces infections dramati cally, saving lives  and reducing healthcare costs.  Take a minute to review these interventions, by clicking here , to assure your facility is do ing everything possible to be safe and save lives.
  
Learn New Approaches to Healthcare Improvement Using IHI's Framework
 
To support your participation in the Network's 2018 quality improvement activities (QIAs), we invite you to review the Institute for Healthcare Improvement's (IHI) Model for Improvement, an approach that IHI uses as the framework to guide improvement work. Developed by Associates in Process Improvement, the Model for Improvement is a simple, yet powerful tool for accelerating improvement. It is not meant to replace change models that organizations may already be using, but rather to accelerate improvement.
 
Learn about the fundamentals of the Model for Improvement and testing changes on a small scale using Plan-Do-Study-Act (PDSA) cycles. The Plan-Do-Study-Act (PDSA) Worksheet is a useful tool for documenting a test of change. The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act). Additionally, root cause analysis (RCA) is a process widely used by health professionals to learn how and why errors occurred.

To learn more about the Quality Improvement Essentials Toolkit and view all available tools, visit  http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx
  
Release of Monthly Quality Improvement Activity Calendar

As the Network initiates its new CMS Quality Improvement Activites (QIAs), we recognize that facilities may be participating in more than one of our projects. So to support and assist facilities with managing these projects, the Network has developed a resource calendar to include important reminder dates such as webinar kick-off dates, reporting due dates, ESRD NCC LAN calls and any other pertinent dates associated with the QIA. This calendar will be color coded by project involvement and will be available from your Network QIA Lead and by accessing the ESRD website for a printable version. 

A printable version will be available on the Network's website:  http://network2.esrd.ipro.org/events/ 

Patient Services
Understanding the Importance of Vocational Rehabilitation for ESRD Patients

For many years, Vocational Rehabilitation (VR) and Employment Networks (EN) were thought of as programs for individuals without a disability. Today, more people with disabilities are finding out that is not true and that VR/EN is more than just about employment. In the article titled " Vocational Rehabilitation for People with Disabilities" Gloria K. Lee describes employment as a fundamental right for people with disabilities. She goes on to define VR from an intervention perspective describing the complex process of VR and the different components involved. By reading this article you will understand the importance of assisting ESRD patients in obtaining in VR/EN services to improve their quality of life.    
  
Emergency Preparedness: What to Know and When to Report

Emergencies caused by severe weather or disasters can happen without warning. Transportation barriers, changes in water, loss of power, or access to supplies can critically impact dialysis treatment. 
Therefore, it is important to be prepared before an emergency occurs.  In addition to routine review of disaster plans, resource management, drills, and updating contact numbers and medication records, dialysis facilities are encouraged complete the following action items to ensure continuity of care:
  • Designate in CROWNWeb a Disaster/Emergency Coordinator for your facility. Be sure to include a cell phone number.
  • Conduct a Hazards Vulnerability Assessment to determine how and when your facility might be at risk.
  • Establish a Mutual Aid Agreement with a back-up dialysis provider that will accept your patients if your facility cannot provide access to care.
  • Annually contact your local Office of Emergency Management (OEM) to communicate patient census and needs of ESRD patient care during an emergency.
Reporting Operational Status to the Network
In an emergency, the Network is required by CMS to work with Federal, State and local government agencies to assist with patient safety and ensure dialysis facilities are prioritized to be open for treatment.  Networks are also tasked with tracking the status of facility operations and patient access to care during events.  If your facility becomes inoperable or inaccessible due to an emergency, it must be communicated to the Network as soon as possible.  This improves the ability of the Network to provide current information to assist patients, the renal community, and emergency management personnel.
  
For questions about facility emergency preparedness requirements, resource materials, or technical assistance, please contact the Network at  516-209-5578.

  
Join the 2018 CMS National Learning and Action Networks!

Be part of the ESRD National Coordinating Center's (NCC) 2018 Learning and Action Networks (LANs). These LANs each focus on one of the following topic areas:

Patient Engagement
Patient Experience of Care 
HAI
Transplant
Home Modality
Population Health project -Vocational Rehab

Participation on the LAN will allow your facility to hear successful strategies and best practices on a national level, learn from expert speakers in the community, and support your work in reaching your QI goals.  Your participation will give you access to LAN conference calls that are held every other month. LAN participants meet to share best practices, develop resources and provide feedback from facility  staff members. 

The ESRD NCCLANs will support facilities in more efficiently achieving the goals of the QIAs and sustaining the improvements achieved by:
  • Creating a diverse forum, that includes patients, representatives of dialysis facilities and stakeholder organizations, for addressing problematic issues
  • Using measurable and clear goals with proven effective practices to drive decision making
  • Setting the pace and tone for goal related activities and to create an open sharing of practice and data
  • Initiating change methodology which rapidly tests small quality improvement changes specific to the area of work.
Register today to join an ESRD NCC LAN!  https://www.surveymonkey.com/r/NCC2018LAN

  
Place Your Order Today! Educational Resources Available through New Online Order Form

The IPRO ESRD Network of New York is pleased to release a new online order form  to help you easily request printed copies of a variety of educational resources and Network publications. The Network also offers a comprehensive electronic library of educational resources and materials for patients, family members, facility staff, and community stakeholders.

Network resources are available free of cost and cover a wide range of topics that include patient-to-provider communication, grievance resolution, patient engagement, peer mentoring, home therapies, vascular access, transplant, infection prevention, and more.  
 
Please visit our website to review our education materials, download PDF versions, or complete an Online Order Form located on the Publications and Resource tab of our website, to request copies of printed materials. Requested materials will be mailed to your facility.

Data Management
Data Submission in CROWNWeb for Newly Open and Pending Certification Facilities 


As of January 1, 2018, new dialysis facilities can access CROWNWeb before becoming certified by their local state survey agency.  ESRD Networks are now able to set up a new facility in CROWNWeb prior to a CMS Certification Number (CCN) being established.  While the new facility is waiting for certification, facility users/staff can be created in CROWNWeb, and data submission can begin at the facility level. 
 
If a new facility is scheduled to open, please contact the Network as soon as possible to let us know.  Timely access to CROWNWeb will ensure compliance with data submission requirements of the End Stage Renal Disease Quality Incentive Program (ESRD QIP).


  
ESRD QIP Payment Year (PY) 2019 CROWNWeb Reporting and Attestation Deadline 

The Calendar Year (CY) 2017 End-Stage Renal Disease Prospective Payment System (ESRD PPS) Final Rule requires facilities to report data into CROWNWeb before the clinical month closure.  As a reminder, all CROWNWeb reporting and attestations for the End-Stage Renal Disease Quality Incentive Program (ESRD QIP) are due at the end of the last clinical month of the reporting period.

The second reporting period for the ESRD QIP Payment Year (PY) 2019 Pain Assessment and Follow-Up and Clinical Depression Screening and Follow-Up reporting measures, and the attestation period for the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Survey measure close on February 28, 2018, at 11:59 PM Eastern Time, which is in alignment with the December 2017 clinical month closure.
 
For upcoming deadline information, please see the monthly editions of the CROWNWeb Newsletter or ESRD QIP page on MyCROWNWeb.org.  If you have any questions or concerns, please contact the ESRD QIP team at esrdqip@cms.hhs.gov.
  
CROWNWeb End Users: Upcoming ESRD QIP Data Validity and Reliability Study

The Centers for Medicare & Medicaid Services (CMS) has contracted with RELI Group to assess the reliability and validity of the Clinical Performance Measure (CPM) data entered into the CROWNWeb system and Dialysis Event data entered into the Center for Disease Control (CDC) NHSN system. RELI will be randomly selecting 335 ESRD facilities to participate in this validation effort. Of those selected, 300 facilities will be sampled to submit records pertaining to CROWNWeb data and 35 facilities will be sampled to submit records pertaining to NHSN data.
  
If your facility is not selected for validation, there is nothing more to do. If your facility is selected to participate in the validation you will receive a Request Letter via USPS Certified Mail. These requests are scheduled to go out in February 2018. If you are part of a Large Dialysis Organization (LDO), your corporate office may receive your request and contact you for any necessary records.

Please note: you will be required to sign for the letter; if no one is available to sign at the time of delivery, the US Post Office for your area will hold the letter until you are able to retrieve it. In this case, a notice will be left at your facility.
  
The Request Letter will include:
  • The list of patients sampled from your facility (maximum of 10)
  • The list of records you will need to submit
  • A thorough explanation of the submission process to ensure that all records are submitted to RELI in a secure manner
Facilities that do not respond to this request will receive a 10-point reduction in their End-Stage Renal Disease Quality Incentive Program Total Performance Score (ESRD QIP TPS).
 
For questions on the Upcoming ESRD QIP Data Validity and Reliability Study, contact Gladys Happi, MSN, RN, CNN, ESRD Clinical Data Lead/Deputy PM at ghappi@hcdi.com.
CMS color logo
  
Have you Completed your Annual NHSN Dialysis Event Surveillance Training?

The NHSN is an electronic tracking system for healthcare-associated infections (HAIs) that integrates patient and healthcare personnel surveillance systems managed by the CDC. To fulfill the annual NHSN training requirement, at least one NHSN user at each facility must read the Dialysis Event Protocol and subsequently take the online Dialysis Event Surveillance Training before September 30, 2018. By completing the Annual Training and passing the post-training assessment, individuals are eligible to earn continuing education credits (CE) , provided they complete this process online.

  
Kidney Community Emergency Response (KCER) Alerts and Information
  • Click here for up-to-date KCER Alerts and Recalls.
  • For professional and patient KCER resources, please click here.
  
Learning and Action Network (LAN) Information and Resources

IPRO End-Stage Renal Disease Network of New York, the ESRD Organization for the state of New York, prepared this material under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMS Contract Number: HHSM-500-2016-00020C.
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IPRO ESRD Network of the New York State
1979 Marcus Avenue  Lake Success, NY 11042
PH 516-209-5578   Ā· FAX 516-326-8929
 info@nw2.esrd.net