January 9, 2017
Network Hosted Webinar Event!
IPRO ESRD Network of New England will host a webinar event on Thursday, January 12, 2017, 2:00-3:00 PM ET. The webinar will provide an overview of the Network's 2017 activities and detail the Centers for Medicare & Medicaid Services' (CMS) expectations for the 2016-2020 ESRD Statement of Work.
Participation by designated Network Council Representatives from each dialysis facility in New England  is requested.
To register click here, and for more information click here or contact the Network at (203) 387-9332.
Finalized Payment Year 2018 Reporting Measure:
Pain Assessment and Follow-Up Reporting
Measure Description
Facilities must report in CROWNWeb one of the following six conditions for each qualifying patient; once before August 1, 2016 and once before February 1, 2017. Based on NQF #0420.

1) Pain assessment using a standardized tool is documented as positive and a follow-up plan is documented
2) Pain assessment documented as positive, a follow-up plan is not documented, and the facility possesses documentation that the patient is not eligible
3) Pain assessment documented as positive using a standardized tool, a follow-up plan is not documented, and no reason is given
4) Pain assessment using a standardized tool is documented as negative, and no follow-up plan required
5) No documentation of pain assessment, and the facility possesses documentation the patient is not eligible for a pain assessment using a standardized tool
6) No documentation of pain assessment, and no reason is given 

1) Patients who are younger than 18 years
2) Patients treated at the facility for fewer than 90 days
3) Facilities with a CCN open date after July 1, 2016
4) Facilities treating fewer than 11 qualifying patients during the performance period
Data Sources REMIS, CROWNWeb, and other CMS ESRD administrative data 
Additional Information
Conditions covering the first six months of the performance period must be reported in CROWNWeb before August 1, 2016, and the conditions covering the second six months of the performance period must be reported in CROWNWeb before February 1, 2017.

Quality Improvement
What is the ESRD Quality Incentive Program (QIP)?
The Centers for Medicare & Medicaid Services (CMS) administers the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) to promote high-quality services in outpatient dialysis facilities treating patients with ESRD. This program changes the way CMS pays for the treatment of patients with ESRD by linking a portion of payment directly to facilities' performance on quality of care measures.
The ESRD QIP will reduce payments to ESRD facilities that do not meet or exceed certain performance standards. The maximum payment reduction CMS can apply to any facility is two percent. This reduction will apply to all payments for services performed by the facility receiving the reduction during the applicable payment year (PY).

QIP Resources:
Hand Hygiene Audits Over Report Compliance
Physicians and nurses are significantly more likely to comply with hand washing guidelines when they know they are being watched, a new study suggests. The finding,  published online   in the July 5 issue of the Journal of Hospital Medicine, suggests that traditional audit methods that include the use of overt auditors to monitor clinician adherence to hand hygiene protocol may substantially over-report compliance.
To determine whether and to what degree a phenomenon called the Hawthorne effect, in which individuals alter their behavior when they know they are being watched, influences hand hygiene behavior among physicians and nurses, Adam Kovacs-Litman, BSc, from the Centre for Quality Improvement and Patient Safety at the University of Toronto, Ontario, Canada, and colleagues compared rates of compliance measured by covert observers and overt auditors during a two-month period.

The World Health Organization (WHO) recommends that  healthcare providers clean their hands
  • before and after touching a patient or their surroundings,
  • before any procedure, and
  • after they come into contact with bodily fluids.
To read the full article, click here.
Nephrology Faces a Lack of Nurse Recruitment
In a  letter to the editor  published in the from June 2016 issue of Nephrology News and Issues, Tamara Kear PhD, RN, CNS, CNN, assistant professor of nursing at Villanova University outlined the challenges in recruiting novice nurses to nephrology, and how it adds to dialysis nurse burnout.

  According to Dr. Kear, "Nephrology nurse practice settings, particularly dialysis units and clinics, face challenges in hiring nurses and staffing units. The topic of understaffing and difficulty in filling vacant positions is a common topic of conversation among nephrology nurses.  Many of today's new hires come from the pool of nurses with varying years of experience in the acute care setting. It is difficult to attract novice nurses into the nephrology practice settings."
Click here to continue reading the full article in Nephrology News and Issues.
Patient Services
Patient Experience Webinar
The National Forum of ESRD Networks is continuing its Patient Experience Webinar series with Webinar #4, Continuing the Discussion, Answering Your Questions

When: January 25, 2017, 2:00 PM ET
Save the Date - Registration will be available soon.

This webinar will focus on two topics that received the most comments and questions:
  • Breaking down barriers to engaging professionals, administration and patients
  • How to get started: Peer Mentoring & Patient Advocacy
Managing Diabetes in the Workplace
The Diabetes at Work website is a resource of the National Diabetes Education Program (NDEP), a program of the National Institutes of Health and the Centers for Disease Control and Prevention (CDC). Launched in April 2002, Diabetes at Work is the first online resource specifically designed to address the management of diabetes in the workplace.

Visit the CDC Diabetes at Work website, for more information and helpful resources including:
Data Management
ACTION NEEDED - Performance Score Reports for Payment Year 2017 
Payment year 2017 Performance Score Certificates (PSC) are available for download as of December 15, 2016. Facilities will be able to access their PY 2017 PSCs until the start of the PY 2018 Preview Period next summer. CMS encourages facilities to retain the Portable Document Format (PDF) file containing their PSCs so that they may generate a replacement paper copy as needed throughout 2017. The PSC is a document that facilities are required to  post in a prominent area for patient viewing throughout 2017.
The Final Performance Score Reports (PSRs) will be available for download after the first of January. While we know that final Total Performance Scores (TPS) are correct, we have identified a few formatting issues that we intend to correct before releasing. CMS will send notifications to facilities once the final PSR availability date is confirmed. 
Accessing PSCs:
  1. Go to https://cportal.qualitynet.org/QNet/pgm_select.jsp
  2. Log in End Stage Renal Disease Quality Incentive Program QIMS/ CROWNWeb user credentials  
  3. Enter passcode received via email
  4. Once logged in, change the organization type to facility QIP by going to the user profile tab (at the top right side of the screen) then clicking the user preferences drop down tab
  5. Go to "My Reports" and then "Run Reports"
  6. Click on "Run Reports" again and the click on "View Reports"
  7. Select "Performance Score Certificate"
  8. Provide required parameters and click submit
  9. Go to "Search Reports" and "Select the Report"
  10. Click on Download
If you need further information or assistance, please contact Krystle Gonzalez at kgonzalez@nw1.esrd.net. Please note: Due to a large number of emails and phone calls received by the Network, emails will be answered in the order they are received. We request your patience as we respond to emails during this holiday season. 

Have Your Key Facility Personnel Been Updated in CROWNWeb?
CROWNWeb Data Management Guidelines require that key facility personnel are added within five business days of staff changes. The guidelines also indicate that facility staff should review personnel information at least quarterly.
As an efficient and cost effective way to communicate with our community, the Network relies on email to send important information. The Network started a new contract year on December 1, 2016, and new quality improvement activities will soon be initiated. As you know, CROWNWeb is the Network's source for facility personnel contact information.
To ensure that the appropriate individuals at your facility receive critical information from the Network on an ongoing basis, CROWNWeb must reflect current and up-to-date information for key personnel at your facility.
Please verify facility/personnel contact information in CROWNWeb for accuracy.   Anyone with access to CROWNWeb can update facility personnel information. It is very important that personnel contact information (including name, job description, JOBCODE, job title, email, and phone number) for key staff members at your facility is kept up to date in CROWNWeb.
Transplant centers that do not have access to CROWNWeb can fax the information to the Network at 203-389-9902.
The key staff members include only those personnel with job descriptions and job codes listed below.

Key staff members are:

Job Description
Facility Head Nurse/Nurse Supervisor
Facility Social Worker
Facility Dietitian
Facility Medical Director
Facility Administrator
Facility Nephrologist
Facility Data Contact

The facility personnel screen in CROWNWeb is divided into three sections:
  • Key personnel info - complete all the information
  • Positions - create as many positions as required. If any staff member's position changes, e.g., Medical Director, remove the position. Do not delete or deactivate the staff member. One can add and remove as many positions as needed.
  • Personnel contact info - Email is required.
Use the Network Data Knowledge Base and Customer Portal
With the increase in data that must be submitted, as well as systems through which the data is collected, there are multiple ways in which you can reach the Network Data Support Team for help. 
*Please remember that you should NEVER include any patient-specific information such as Name, Date of Birth, Social Security Number, Medicare Claim Number, etc. The only patient identifier that can safely be communicated is the Unique Patient Identifier (UPI) from CROWNWeb.*
Upcoming Meeting & Events
Thursday, January 12, 2017 - 2017 Network Activities and CMS Expectations webinar hosted by IPRO ESRD Network of New England

IPRO End-Stage Renal Disease Network of New England, the ESRD Organization for Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont, 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-500-2016-00019C.