Quality Improvement Data Collection and Reports
The following information describes the current CMS/Network 8 quality improvement data collections and reports distributed to facilities.
Facilities must make the information contained in the following reports available to patients or inform patients on how to contact the Network to obtain this information.
Patient-specific lab data by facility are collected annually, through electronic submission from Large Dialysis Organizations (LDOs) to CMS and through manual data submission from non-LDO facilities to the Networks. Non-LDO facilities are notified by mail and are supplied with a data collection tool and instructions for data submission. Lab data is collected for 100% of the defined patient population. Current lab elements include:
TSAT (if done)
Ferritin (if done)
Kt/V for HD pts
Weekly CrCl for PD pts
Weekly Kt/V for PD pts
Data analysis is performed to profile each facility’s performance in accordance with CMS goals for clinical performance measures. The Network utilizes this as the basis for facility recognition and intervention activities. Reports, distributed to each facility, provide comparisons of facility data to state and network data.
Elab National Trends Report 6-2012
In 1998 and 1999, Network 11 demonstrated that facility-specific profiles could be generated from lab data that was electronically submitted directly from the laboratory to Network 11. This project, which came to be known as Elab, expanded to three Networks in 2000 and six Networks in 2002. For the fourth quarter 2011 data collection, the project included all 18 ESRD Networks and nearly 100% of dialysis patients and facilities. The facility-specific reports generated from the lab data offer comparative data at the state and Network level and can be used for quality improvement purposes.
Click here to view the 2011 National and Trends Report http://www.esrdnet11.org/Elab/index.asp
Fistula First Data Collection and Reports
In conjunction with the Fistula First Breakthrough Initiative, the ESRD Networks collect patient-specific vascular access data on a monthly basis. The data are reported by the number of patients using defined access types at a specific point in time (the last treatment day of the month). All outpatient hemodialysis facilities are required to submit vascular access data, as described below.
Data from LDO facilities are electronically transmitted from the corporate office directly to a CMS data contractor, and then to CROWNWeb. This information is uploaded from the computer systems within each dialysis facility. To assure data accuracy, facility staff should update vascular access types in computer records, as they change.
Non-LDO facilities in Network 8 submit data through CROWNWeb data entry also, either at the facility level (single-user interface) or via approve Health Information Exchange such as NRAA.. New non-LDO facilities should contact Network 8 QI staff if assistance is needed with vascular access data entry into CROWNWeb.
Fistula First data feedback reports will be distributed quarterly to facility medical directors, nurse managers and administrators. We encourage facilities to use the reports in quality improvement activities.
Dialysis Facility Reports (DFR)
The Dialysis Facility Reports are prepared by the University of Michigan Kidney Epidemiology and Cost Center (UMKECC) annually, and distributed by the Network to facility medical directors and administrators. The reports contain facility-specific patient characteristics, treatment patterns, transplantation rates, hospitalization rates, and mortality rates, and compare them to state, Network and national data.
The report is based on data from Medicare dialysis and hospitalization claims, Medical Evidence Forms (CMS-2728), Death Notification Forms (CMS-2745), Annual Facility Survey Reports (CMS-2744), other CMS data and Social Security Administration data.
The purposes of the report are:
- To provide advance notice of updated quality measures to be posted on the Dialysis Facility Compare (DFC) website and allow submission of facility comments to CMS about DFC measures. See the following information regarding DFC website.
- To provide notification that the DFR will be sent to the State Survey Agency (SSA) for use in survey activities and to provide instructions for submitting facility comments, to be appended to the report sent to the SSA.
- To use as a tool in quality improvement activities.
Network 8 utilizes the reports in conjunction with other facility-specific data to profile facilities and develop quality improvement activities.
To access the 2012 DFR User's Guide, click here http://www.dialysisreports.org/Methodology.aspx
Dialysis Facility Compare (DFC) Website ( www.medicare.gov/Dialysis/Home.asp)
The DFC website was created by CMS to provide information regarding dialysis facilities (certified by Medicare) to patients, families and healthcare professionals. Information provided on the website is listed below. Resources and links to other websites are also included to provide information on kidney disease and dialysis treatment.
Dialysis Facility Services
- address and telephone number of the facility,
- the facility's initial date of Medicare certification,
- shifts starting at 5 PM or later (if you need your treatments in the evening),
- the number of treatment stations,
- the types of dialysis offered (in-center hemodialysis, peritoneal dialysis, and home hemodialysis training),
- facility ownership type (profit or non-profit), and
- corporate name (if applicable)
Quality Measures (displayed on Compare Quality Tab)
- Hemodialysis adequacy
- Patient survival
Network 8 Annual Report
Presents an overview of activities conducted by Network 8, Inc. Reports are submitted to CMS in July and posted on the Network 8 website following CMS approval.
Other Data Collections
On occasion, CMS requires the Networks to collect data for the United States Renal Data System (USRDS) and other approved entities. Facilities will receive notification regarding any additional data collection not mentioned above.