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Quality Improvement Data Collections and Reports

The following information describes the current CMS/Network 8 quality improvement data collections and reports distributed to facilities. Facilities will be notified as changes are made in data collection projects, as will occur with CROWNWeb, a web-based software program that CMS will require each facility to use at some point during 2009. For more information on CROWNWeb, visit the Network 8 website.

 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.

 Clinical Performance Measures (CPM) Project

The Clinical Performance Measures Project is a collaborative effort CMS, the ESRD Networks and the ESRD dialysis facilities. The project is designed to improve patient care and outcomes by providing comparative data on clinical performance measures in the areas of dialysis adequacy, anemia management, vascular access practices, bone disease management and nutrition.

Historically, the data were collected annually on a random sample of adult in-center hemodialysis and peritoneal dialysis patients by paper forms. This data collection will change with the implementation of CROWNWeb, and will not be conducted in 2009.

More information about the CPM project and previous reports are available on the CMS website: www.cms.hhs.gov/CPMProject/ .

Lab Data Collection Project and Reports

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:

 

Hemoglobin

Albumin method

TSAT (if done)

Phosphorus

Ferritin (if done)

Kt/V for HD pts

Pre BUN

Weekly CrCl for PD pts

Post BUN

Weekly Kt/V for PD pts

Albumin

Calcium

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.

Fistula First Data Collection and Reports

In conjunction with the Fistula First Breakthrough Initiative, the ESRD Networks collect facility-specific vascular access data on a monthly basis. Currently, only aggregate data are collected. 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 the Networks. 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 to the Network by fax or email, using a paper form or Excel spreadsheet. These reports are due to the Network office by the 20 th of each month. (Example: January data is due February 20.) New independent facilities should contact the Network 8 office to begin data submission.

Click here for data forms and instructions.

(To more efficiently download the larger files, right-click the link and choose to "Save target as..." and save the file to your computer.)

With the implementation of CROWNWeb, the process for submitting vascular access data will be changed. The data will be entered into the CROWNWeb system from LDO corporate batch downloads and from manual entry by non-LDOs. This data will be patient-specific and include additional data elements. More information will be available upon full implementation of the system.

Fistula First data feedback reports are distributed twice yearly to facility medical directors, nurse managers and administrators. We encourage facilities to use the reports in quality improvement activities. These reports currently consist of three standard reports, developed by CMS, plus two Network 8 specific reports.

The reports are described below:

  1. Fistula Use and Placement Rates in Incident Patients – describes the number of incident patients (new patients starting dialysis that month) and type of access used for dialysis, plus other access types present, but not used. This report depicts the percentage of incident patients beginning dialysis with an AVF in place, whether used or not.
  2. Vascular Accesses Used in Prevalent Patients – describes the number of prevalent (current) patients and type access used for dialysis on the last treatment day of each month.
  3. Fistula Rate Comparison, Prevalent Patients: Facility, Network, US – describes the number and percentage of prevalent patients using an AVF for dialysis on the last treatment day of each month, compared to the number and percentage of prevalent patients in the Network and US using an AVF.
  4. Facility Prevalence Rates for Catheters – NW 8 specific report describing the number and percentage of prevalent patients dialyzing with catheters in the following categories: catheter > 90 days, catheter < 90 days, catheter with AVF present, and catheter with AVG present.
  5. Catheter Prevalence Rates Comparison - NW 8 specific report describing the number and percentage of prevalent patients dialyzing with a catheter for > 90 days compared to number and percentage of patients in state and Network 8 using long-term catheters.

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:

Network 8 utilizes the reports in conjunction with other facility-specific data to profile facilities and develop quality improvement activities.

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)

  • Anemia
  • 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.

 

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