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Welcome to the January 23 issue of the Quality Insights Renal Network 4 e-newsletter. In this issue, we bring you information about National Healthcare Safety Network (NHSN) updates, Centers for Medicare & Medicaid Services (CMS) updates, continuing education opportunities, patient education features, ESRD events, resources and much more. We encourage you to  contact us with any questions, concerns or suggestions.  
FeedbackPlease provide us with your feedback on last month's Facility-LED PATIENT EDUCATION
Please take this short survey to let us know what you thought about last month's facility-led patient education topics
esrd qip performance score certificates
We will be providing a Network 4 Patient Education Sheet each month in 2018. These documents are also located on  our website. Please provide all of your patients with this education sheet this month.   Also, we ask that you please encourage your facility's Patient  Representatives to pass out this educational information as well. 
NetworkGoals2018 Network Goals: Attestation Link Available
Quality Insights Renal Network 4 is providing Network facilities with 2018 Network 4 Goals. We ask that you attest in the following site after you receive and review these goals. If you oversee more than one facility, please add all of the CCN in one attestation. Access the attestation here.  
UpcomingEventsUpcoming Events

Delaware ONLY: KEPRO's Free Patient Navigation Program and Webinar Opportunity
For Medicare beneficiaries, understanding their doctor and making their way through difficult medical systems and treatments can be very overwhelming. KEPRO's free Patient Navigation program can help people with Medicare be a partner and take control of their own health. KEPRO's Patient Navigators can work 1-on-1 with Medicare beneficiaries to: 
  • Help coordinate care 
  • Offer tips on how to manage medications 
  • Help better understand a diagnosis or treatment plan 
  • Provide resources and information to help patients understand, treat, and prevent diseases
  • Help improve quality of life
The following is an example of how the Patient Navigation program works. In this example, a Medicare beneficiary was discharged from a rehabilitation facility under the care of his wife after a brain bleed. His wife requested that he join the Patient Navigation program after his appeal was denied. He was able to walk with a front-wheeled walker, although he was independent before his hospitalization. His discharge plan was for home health, and he had no medical equipment at home. He had an upcoming visit with his primary care physician, and his wife was unsure how she would transport him.

KEPRO's Patient Navigator was able to assist the wife with setting up transportation for the doctor's appointment. The Patient Navigator also followed up with the home health agency, as the wife needed additional medical equipment, such as a shower chair. The Patient Navigator followed and assisted this beneficiary for 32 days to make sure there were no further needs and that he was progressing well with the home health agency.

KEPRO's Patient Navigation program is available for Fee-for-Service (FFS) Medicare beneficiaries. This program is part of their benefits from Medicare and is offered at no cost to them.
Please encourage your FFS Medicare beneficiaries to contact KEPRO for their healthcare navigation needs. Learn more about KEPRO's Patient Navigation program.

Special Webinar Opportunity: This webinar will present a basic overview of KEPRO's services as well as an introduction to some provider-based services. 

What: BFCC-QIO Program Overview
Who: Healthcare providers and stakeholders
When: January 25, 2018 from 2:00 to 3:00 p.m. ET
Speakers: Andrea Plaskett, Outreach Specialist, KEPRO; Brittny Bratcher-Rasmus, Outreach Specialist, KEPRO
Webinar Details: Register here

Download the Patient and Family Engagement toolkit to learn more about the new tools and resources. 

Webinar Opportunity: Resumes that Get Results - January 25
Employment Options hosts free webinars throughout the year on helpful topics for job seekers and recruiters. Whether you need tips for resumes, do's and don'ts of interviews or applications, or to learn about the free Social Security Ticket to Work program, the Employment Options staff have you covered. The next webinar event will take place on Thursday, January 25, 2018 and will cover the topic  Resumes That Get Results. Learn more and register

Registration Now Open for RPA's Billing and Coding Conference
Knowing and understanding the rules of the game are the keys to proper billing, coding and documentation. The Renal Physicians Association (RPA) Billing and Coding conference is scheduled for   March 15, 2018   in Orlando, Florida and can help physicians, practice managers and coders gain greater understanding around office, hospital and dialysis coding. Jeffery Giullian, MD , Rob Blaser and Leland Garrett, MD will be presenting for this dynamic, fundamental, interactive workshop. Registration is now open.

Registration Now Open for the Latest National Kidney Foundation Patient & Community Education Seminar
Registration is now open for the National Kidney Foundation's latest Patient & Community Education Seminar, Everyday Heroes Living with Kidney Disease. The seminar will take place on  Sunday, March 25, 2018 from  1:30 to 5:30 p.m. at the  South Philadelphia Community Health and Literacy Center located at  1700 South Broad Street,  Philadelphia, PA 19145.  The National Kidney Foundation invites kidney patients from early stages of kidney disease to dialysis or transplantation and their caregivers to come together, learn and become empowered through this Patient Education Program.  To register, contact Eleanor at (215) 923-8611 ext. 743 or email . This seminar is s ponsored by Pentec Health.

2018 National Kidney Foundation Spring Clinical Meetings
The 2018 National Kidney Foundation Spring Clinical Meetings (SCM) will be held in Austin, TX on April 10-14, 2018.  The SCM website features a comprehensive preliminary program, a call for abstracts, a sign-up area for news and a link to the NKF Professional Education Resource Center (PERC) that will have many free-to-members courses based on the 2017 SCM.  SCM includes separate pre-conference workshops and conference tracks for physicians, pharmacists, advanced practitioners, nurses, technicians, dietitians, social workers, and transplant professionals.  Registration is now open, and discounted advance registration closes January 26, 2018. Learn more
NHSNUpdatesNHSN Updates
third quarter 2017 dialysis event data should be submitted no later than january 31 
To meet the CMS ESRD QIP NHSN reporting requirements for Payment Year 2019, outpatient hemodialysis clinics must submit their third quarter 2017 Dialysis Event data collected from July 1, 2017 through September 30, 2017, by Wednesday, January 31, 2018. New or revised third quarter data entered into NHSN after January 31 will not be sent to CMS. Therefore, please be aware that any changes or corrections to third quarter 2017 data should be made prior to the reporting deadline.

We recommend using the following resources to review your data before the deadline. These resources and others can be found on the Dialysis Event homepage:
Contact the NHSN Helpdesk (, subject line 'Dialysis') with any questions.

NHSN 8.8.1 to Introduce Updated Agreement 
The January 23 release of the NHSN 8.8.1 application will introduce an updated NHSN Agreement to Participate and Consent for current NHSN facility users who enrolled in NHSN prior to December 2, 2017.  Facilities that enrolled in NHSN on or after December 2, 2017, have already accessed this new Consent and will not need to accept it again if they have already done so.  Primary Contacts or Facility Administrators should agree to this updated Consent form for each component by April 14th, 2018, or risk losing access to NHSN.  Once the Consent form is available on January 23rd, an alert will appear on all NHSN component home pages, and primary contacts and facility administrators will receive an email notification.  Additional information, including Frequently Asked Questions and the updated NHSN purposes, are available on CDC's NHSN website.  If you have any questions, please send an email to with the subject line "NHSN Reconsent."

AKI Patients to Be Included in NHSN Dialysis Event Surveillance
Beginning January 1, 2018, dialysis facilities should include acute kidney injury (AKI) patients in National Healthcare Safety Network (NHSN) Dialysis Event Surveillance. Reporting AKI patient data to a new, separate NHSN location will enable CDC to exclude AKI patient data from NHSN Bloodstream Infection (BSI) information shared with CMS for purposes of the ESRD Quality Incentive Program (QIP).

The "Acute Kidney Injury (AKI) Location" should be used to report Dialysis Events, and denominator data, for patients who have acute kidney injury and do not have an end-stage renal disease (ESRD) diagnosis at the time of the Event, or at time of denominator data collection.
The "Acute Kidney Injury Location" was released as part of the NHSN version 8.8 update on December 2, 2017. Please see the attached instructions for using the "Acute Kidney Injury Location".

Among patients included in the NHSN Dialysis Event Surveillance population, the following criteria should be used to identify patients who have acute kidney injury:

1. No diagnosis of "End Stage Renal Disease" or "ESRD" in the patient medical record, or through the ESRD Medical Evidence Form (Form CMS-2728-U3).
2. Physician-diagnosis of "Acute Kidney Injury" or "AKI" listed in the patient medical record (e.g., nephrologist consult or referral form).
3. The event date, or date of denominator data collection, is not more than 6 months after the date the patient initiated outpatient hemodialysis.

For questions, please contact the NHSN helpdesk at with "dialysis" in the subject line.

2018 Checklist for Reporting Healthcare Personnel Influenza Vaccination Summary Data
With 2018 in full swing, we wanted to review a few points for facilities preparing to submit healthcare personnel (HCP) influenza vaccination summary data for the 2017-2018 influenza season.
  • New requirement: Dialysis facilities that do not provide in-center hemodialysis must complete the Home Dialysis Center Practices Survey before entering HCP influenza vaccination summary data.
  • Keep Secure Access Management Services (SAMS) credentials active. If a NHSN user does not log into NHSN at least once within a 12-month timeframe, he/she will lose access to SAMS and NHSN. NHSN users will also be prompted to change their SAMS password every 60 days.
  • Ensure that at least two staff members can enter data into NHSN.
  • Create a new monthly reporting plan. A reporting plan must be completed once for each influenza season. You will not be able to enter or save any influenza vaccination summary data until you create a reporting plan for that influenza season
  • Select the appropriate influenza season when entering data. For the 2017-2018 influenza season, you must select "2017-2018" in the drop-down box. This is very important, since data submitted under the incorrect influenza season will not be shared with CMS and will not fulfill reporting requirements.
  • Ensure that your CMS certification number (CCN), CCN effective date, and facility type are entered into NHSN. Specific guidance on adding/updating the facility CCN and CCN effective date within NHSN can be found online.
More information on each of the above bullets can be found on pages 13-14 on the NHSN December Newsletter. For your reference, comprehensive training slides can be accessed online
If you have any questions about reporting HCP influenza vaccination summary data, please e-mail

CMSUpdatesCMS Updates

New Q&A Tool Available for ESRD QIP
A new communications tool for submitting questions about the ESRD QIP is now available on QualityNet as the ESRD QIP Q&A Tool. The new ESRD QIP Q&A tool provides a streamlined process to submit questions to CMS subject-matter experts and receive answers in a timely manner on a wide variety of program topics, including issues related to policy, measure specifications, and deadlines. In addition, the Q&A tool provides immediate answers to commonly asked questions through its Frequently Asked Questions (FAQ) feature. A robust search engine allows users to quickly locate information based on keywords or phrases, and it provides a convenient summary of relevant answers.

CMS has posted an overview of the tool in the right-hand "Resources" menu on the ESRD QIP QualityNet home page. In addition, a brief tutorial can be found at ESRD QIP Q&A Tool tutorial. The tutorial guides users to create an account on the tool which will enable CMS to communicate directly with them.

CMS will continue using the ESRD QIP Mailbox to receive and process Extraordinary Circumstances Exception (ECE) requests and supporting documents, payment questions, and facility-specific information. Likewise, facilities should continue to use their accounts on the QualityNet Secure Portal to pose formal inquiries and clarification questions during each year's preview period.

Facilities and the public should not use any of these channels to submit Protected Health Information (PHI) or Personally Identifiable Information (PII) to CMS.

CMS encourages facilities and other stakeholders to access the ESRD QIP Q&A Tool and submit their questions. CMS will redirect questions that come into the ESRD QIP Mailbox to the ESRD QIP Q&A tool.

CMS-2744 Submission Dates Updated
ESRD Networks across the country have come to a consensus regarding the submission dates for CMS-2744 forms. Please have your 2744 generated by February 15, 2018 and submitted for acceptance with NO errors or warnings by March 31, 2018. This means that you may begin working on your surveys at your earliest convenience.

Be aware that Batch Submitting Organizations (BSOs) such as DCI, DaVita, FMC and any other facilities that have data submitted electronically may still have 2017 data being loaded into CROWNWeb (CW) through the beginning of February.

Training on the 2744 is available on the website.  

The training link will take you step-by-step through the 2744 process. Also, the CROWNWeb Outreach, Communications and Training team will begin conducting training by next month. We will inform you as soon as those training dates are available.

Please remember that you are completing the survey for calendar year 2017 and thus will be examining data for activity that took place between January 1, 2017 and December 31, 2017.

Tentative Data Collection Schedule for the 2018 ICH CAHPS Spring Survey
The tentative data collection schedule and the dates for some key activities related to the 2018 In-Center Hemodialysis CAHPS (ICH CAHPS) Spring Survey are shown below. Please note that these dates are subject to change. Should a schedule change occur, an announcement will be posted.
  • Submit New Facility-Specific Questions to CMS - 1/31/2018
  • 2018 Introduction to the ICH CAHPS Survey Webinar Training - 2/14/2018
  • 2018 ICH CAHPS Survey Vendor Update Training Session - 2/15/2018
  • Deadline for Authorizing a Vendor for 2018 Spring Survey - 2/28/2018 
  • Deadline for Submitting a 2018 Facility Non-Participation Form 2/28/2018
  • Deadline for Submitting the Quality Assurance Plan - 3/31/2018
  • Sample Files Uploaded on ICH CAHPS Website - 3/30/2018
  • Vendors Attest to Receipt of Sample File - 4/3/2018
  • Mail Prenotification Letter - 4/20/2018
  • Mail 1st Questionnaire (mail only and mixed mode)/Begin Telephone data collection (phone only mode) - 5/4/2018
  • Mail 2nd Questionnaire (mail only)/Begin phone follow-up (mixed mode) - 6/1/2018
  • Data Collection Ends - 7/13/2018
  • Vendors Clean/Process Final Data and Construct XML File - 7/16/2018 to 7/25/2018
  • Deadline for Submitting XML Data File to ICH Data Center - 7/25/2018
CEUOppsCEU Opportunities

Advanced Renal Education
This educational site provides CEU credits for anyone who completes a course. Register to gain access and complete a course.

American Kidney Fund
The American Kidney Fund offers several online courses that provide free CEs for health care professionals. Learn more

Armstrong Institute for Patient Safety and Quality
The Armstrong Institute for Patient Safety and Quality is now offering short, interactive samples of courses to get a feel for how it creates engaging learning experiences that are relevant and applicable to your work improving patient safety. Samples are now available for the following courses:
  • Patient Safety Certificate Program
  • Human Factors for Patient Safety
  • Becoming a Patient Safety Hero
  • Foundations of CUSP
These samples will work on mobile devices; however, for the best experience use on a laptop or desktop computer. Browse the course catalog for details on all courses, including continuing education credits, learning objectives and costs.

Centers for Disease Control and Prevention (CDC)
The CDC has new free continuing education opportunities available through its Tune In for Safe Healthcare webinar series. Webinars include: 
  • Empowering Nurses to Protect Themselves and Their Patients: The Importance of Collaboration between Nurses and Environmental Services
  • Infections in Dialysis Centers: Understanding what Matters to Patients
  • Empowering Nurses for Early Sepsis Recognition
Institute for Healthcare Improvement (IHI)
Managers and clinical team leaders - check out this one-day Quick Course from the Institute for Healthcare Improvement (IHI) called High Impact Leadership: Developing Core Leaders. Taking place March 8, 2018, in Philadelphia, PA, expert faculty will provide you with practical improvement methods to further develop your leadership skills. By the end of this one-day workshop you will have:
  • A deeper understanding of the four critical core leader competencies
  • Knowledge of where to focus your efforts when it comes to developing your management and improvement skills
  • An understanding of how to shape culture at the team and department level
  • The ability to better develop capabilites within your team
  • Ways to cultivate behaviors crucial to management leadership
Learn more and register

Morbidity and Mortality Weekly Report (MMWR) and Medscape
CDC's Morbidity and Mortality Weekly Report (MMWR) presents a FREE continuing education activity on the following topics:
  • Cancer and Obesity
  • Invasive Cancer
  • Recommendations on the Use of Seasonal Influenza Vaccines

In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. If you are not a registered user on Medscape, please register for free or login without a password and get unlimited access to all continuing education activities and other Medscape features.

ESRDResourcesESRD Resources
Latest edition of KCER Watch is Now Available 
The  December 2017 issue of KCER Watch, the monthly environmental scan that provides timely and pertinent information related to emergency preparedness, is now available. The goal of KCER Watch is to facilitate the exchange of information, sharing of resources, and advancement of knowledge and expertise among ESRD and emergency management stakeholders.

Looking for a Patient Support Group?
Sometimes it's helpful to talk about your journey to kidney health with peers that understand what you're going through. Check out our website periodically for information about local support groups near you, including upcoming meeting dates as they become available. 
Check out the ESRD NCC Information Exchange
The ESRD Network Coordinating Center (NCC) provides centralized coordination and support for the Medicare ESRD Network program. Each month, the ESRD NCC distributes an e-newsletter, known as the Information Exchange, that compiles the most important information from numerous ListServs and publications related to renal health. To sign up to receive this informative newsletter, please contact the ESRD NCC at or visit the ESRD NCC website

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This bi-weekly e-newsletter will serve as our primary method of communicating important news and updates. We encourage you to visit our Web site for the most up-to-date information or to contact us with questions, comments or suggestions.
This material was prepared by Quality Insights Renal Network 4 under contract with the Centers for Medicare & Medicaid Services (CMS). The contents do not necessarily reflect CMS policy.

Publication No. ESRD4-012218