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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 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/ .

ELAB Project

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.

Elab National Trends Report 10-26-09

The national ESRD Elab Project, now in its 10th year, began in 1999 as a method of collecting patient-level, facility–specific data for quality improvement purposes. It was established in 1999 in collaboration with the Large Dialysis Organizations (LDOs) as a small pilot to determine whether or not laboratory data could be collected electronically to decrease the data abstraction burden on dialysis facilities.

The 2008 National Trends Report is divided into two parts. Part one describes the Elab data collection and reporting process and reports the outcomes for Q4 2008 in national aggregate and Network–specific results. Part two of this report describes the specific changes to the Elab process historically, and provides a trending of the national outcomes from Q4 2002–Q4 2008.

Click here to review the report.

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 quarterly 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 newly developed Network 8 specific reports.

The reports are described below:

  1. Vascular Access Outcomes - snapshot of facility number of long-term catheters, AVG, AVF, and number of AVFs needed to meet current Network contract goal.
  2. AVF Outcomes - snapshot of six month facility specific AVF rates
  3. Long-term Catheter Outcomes - snapshot of six month facility specific long-term (> 90 days) catheter rates

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.

To access the 2009 DFR User's Guide, click here.

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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