Transcript ANNA Chapter 125 Clinical Performance Measures Data Validation

ANNA Chapter 126
CROWNWeb Data Validation Project
What’s new in Network reporting?
Knowing your DFR
March 26, 2015
Tricia Phulchand, RN, BS
Data Manager
Quality Insights Renal Network 3
Confidential and Proprietary
Spring is Here???
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What is CrownWeb (CW)?
Consolidated Renal Operations in a
Web-Enabled Network
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CW
 CW was developed to be the next generation in datacollection systems and to help increase the efficiency of data
collection for CMS and for Medicare-certified ESRD
dialysis facilities.
 CMS began this initiative by announcing the development
and release of CW in an updated version of the Conditions
for Coverage for ESRD facilities (CfCs).
 CMS worked closely with stakeholders in the ESRD
community to ensure that CW is a practical datamanagement system that meets the data submission needs of
dialysis facilities, while adhering to requirements set for
federal information systems while supporting CMS goals.
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A Simple Chart
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CMS Data Validation Project
 CMS is just validating data entered into
CROWNWeb
 Any negative results will not count against the
dialysis facility
 2015 data validation is continuation of similar
efforts in 2013 and 2014
DO NOT PANIC
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Purpose of Validation
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Improve reporting
Improved training
Receive input from users
Identify workflow issues
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So Why Tell Us About This?
 Prepare you personally if you receive a letter
from Healthcare Management Solutions
 Prepare your facility for future audits
 Identify gaps in documentation
 Ensure submission is completed accurately
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How Many Facilities are
Included?
 There are over 6,000 dialysis in the US and
Territories
 Each year CMS randomly selects 200-500
facilities and 2-3 patients within each facility
 Patient’s names and SSN are noted in the letter
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Contracted Company
 Healthcare Management Solutions, LLC (HMS)
 Letter will come from this company to facility
DON’T THROW IT AWAY!!
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Date of Submission
 Documents must be sent to HMS by designated
date in letter
 Secure submission directions are provided
 Provide a list of the specific documents they
will review and the time period covered
(3 months)
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Sample Letter Requested
April, May and June 2014
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All Lab reports/results
Residual renal function (PD only)
All treatment flow sheets
All MD orders
All nursing and MD progress notes
All standing orders for medications and vascular access
monitoring
 All results of VA monitoring for specific patients
 All VA surgical reports and patient specific VA documents
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Example of HMS data request letters from 2013:
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Requested Policies
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Vascular access physical examination
Surveillance of AVG with doppler ultrasound
Arterial pre-pump pressure for AVF/AVG
Surveillance of AVG by static venous pressure
Surveillance of AVG with Intra-Access Flow performed
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Calculation Methods/Processes
 Albumin
 V calculation for PD
– BCG/ BCP
 Kt/V
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UKM
Daugirdas II
Depner
Derived from URR, no
patient weight
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% body weight
Hume
Watson
Other
 Surface area PD
– Dubois & Dubois
– Other
You may have to call your lab to find these answers
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MD Orders
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ESA Prescribed
Date of ESA prescription changed
IV Iron
Date IV iron prescription changed
Date Access type for dialysis changed
Prescription changed after adequacy measurement
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Progress Notes legible, date and time
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Treatment Start Date
Kt/V (HD)
Kt/V HD collection date
Date access type
changed
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 Access physical exam
 Access physical exam
frequency
 Static venous pressure
 Static venous pressure
frequency
Progress Notes - Continued
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Doppler
Doppler frequency
Intra-access flow
Intra-access flow frequency
Prescription change after adequacy measurement
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Laboratory Report
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Kt/V HD
Kt/V date
Kt/V Method
Hgb and Hgb date
Ferritin and date
TSAT and date
Retic Hgb (CHr) and date
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 Phosphorus and date
 Corrected Calcium and
date
 Uncorrected Calcium and
date
 Albumin, range and date
 Albumin method
Laboratory Report
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Date PD adequacy measurement
Weekly Kt/V PD
Kt/V PD method
Body surface area method
Residual renal function assessed in calculating
Kt/V
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Treatment Flow Sheets
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Patient’s identifiable information
Pre and post weight
Pre and post BP
Initial assessment
Prescribed treatment
Administered medications
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Treatment Flow Sheets
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Modality
Primary type of treatment
Treatment start date
Sessions per week
ESA prescribed and Lab
work
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Access type
Date of dialysis session
Date Access type changed
Access physical exam
Monitoring vascular
access
Standing Protocols
 Date of initiation
 Detailed clinical events governing the execution
of the standing protocol
 End date or length of time the standing protocol
is to remain as a governing order
Date ESA prescription changed
Date IV iron prescription changed
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Secure Submission
Requirements
3 Options
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Closely follow the written
directions… PDF Submission
 Make sure you use patient coversheets provided
by HMS between patients.
 Include a face sheet that includes your
organizations name and contact information
 Password protect the document (password
given in mailing)
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Option 1
 PDF Submission
– On CD, DVD or flash drive
 Mail in tamper-evident packaging
 Return receipt
 Mail to address in mailing
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Option 2
 Fax Submission – use only if PDF is not an
option
 Fax must be in a secure area where you can
observe and control the sensitive info.
 Coversheet must include
– Total number of pages
– Contact information for the facility
– Notify HMS if faxing in several packets
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Option 2
 Fax number contained in letter
 Observe safeguards: documents containing
Protected Heath Information (PHI) and/or
Personally Identifiable Information (PII) must
be immediately cleared from printers and fax
machines. Paper jams in the fax machine or
printer containing private or sensitive data must
be immediately removed and secured.
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Option 2
 Do Not Leave Fax Machine Unattended
 When fax transmission is complete, remove the
original document. Wait for the fax machine to
print the transmission confirmation. All fax
documents will be received directly into a
secure server within the HMS network.
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Option 3
 Paper Submission
MUST BE SHIPPED TO HMS BY
USPS CERTIFIED MAIL ONLY IN
TAMPER-EVIDENT PACKAGING WITH
RETURN RECEIPT
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Option 3
 Ensure all documentation is in the proper order
 Clipped together No Staples
 Face sheet with facility info and contact
information
 Mail to address in letter
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Questions?
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QIRN3’s Data Sources
We are able to pull data from multiple sources and
create NW reports.
 Vascular Access Reports
 Annual and Quarterly
Dialysis Facility Reports
 Quality Incentive
Program Reports
 CROWNWeb data
 Grievances
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 NHSN Reports
 New Clinical Data
Reports from CW
 DOH Federal survey
results and
communication
 On-site visits
Facility Vascular Access
Summary Report
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Example of New Report Showing Quarterly Goals
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Patient Specific Report
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Not Reported in CW/ Later Entered- no AVGs maturing
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Vascular Access Trend Report
S
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N
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Quality Incentive Certificate
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2015 QIP Certificate
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A Closer look…
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5 Star Rating System
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Disclaimer
"A 1- or 2- star rating does not mean
that you will receive poor care from a
facility. It only indicates that
measured outcomes were below
average compared to those for other
facilities"
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5 Star Rating
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Purpose of the Report
The 2014 Dialysis Facility Report (DFR) is provided as a resource for characterizing
selected aspects of clinical experience at this facility relative to other caregivers in this
state, ESRD Network, and across the United States. Since these data could be useful in
quality improvement and assurance activities, each state’s surveying agency may utilize
this report as a resource during the FY 2015 survey and certification process.
This report has been prepared for this facility by the University of Michigan Kidney
Epidemiology and Cost Center (UM-KECC) with funding from the Centers for Medicare
& Medicaid Services (CMS) and is based primarily on Medicare claims and data
collected for CMS. It is the nineteenth in a series of annual reports. This is one of 6,371
reports that have been distributed to ESRD providers in the U.S.
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Overview: This report includes summaries of patient characteristics, treatment patterns, and patient
outcomes for chronic dialysis patients who were treated in this facility between January 2010 and
December 2013. Mortality, hospitalization, and transplantation statistics are reported for a three- or fouryear period. Regional and national averages are included to allow for comparisons. Several of the
summaries of patient mortality, hospitalization, and transplantation are adjusted to account for the
characteristics of the patient mix at this facility, such as age, sex and diabetes as a cause of ESRD.
Unless otherwise specified, data refer to hemodialysis (HD) and peritoneal dialysis (PD) patients
combined.
What's New This Year: As part of a continuing effort to improve the quality and relevance of this
report, the following changes have been incorporated into your 2014 DFR. The UM-KECC ESRD
database now includes the new web-based data collection system, CROWNWeb. It was rolled out
nationally in May 2012 and replaces the functionality of SIMS. Authorized users may now securely
submit, update, and verify data provided to Medicare about people who have ESRD on a monthly basis.
Table 14 presents descriptive statistics on a portion of the CROWNWeb clinical data.
In addition, the Influenza Vaccination table (Table 5) has been amended to include a fourth year of
vaccination statistics to assess the percentage of patients vaccinated by December 31st, 2013.
Table 6 now includes a transfusion summary for adult Medicare dialysis patients treated in your
facility and the Standardized Transfusion Ratio (STrR) that allows for national comparison of
transfusion activity.
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Coefficient
Inability to ambulate
Malignant neoplasm, Cancer
Drug dependence
Congestive heart failure
Inability to transfer
Chronic obstructive pulmonary disease
Alcohol dependence
Other cardiac disease
Tobacco use (current smoker)
Diabetes (currently on insulin)
Peripheral vascular disease
Cerebrovascular disease
Atherosclerotic heart disease
Diabetes
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Weight
0.371680375
0.318879608
0.310703703
0.293942558
0.285321945
0.255658337
0.238079181
0.158233847
0.137818834
0.131365189
0.110387762
0.081666976
0.037368308
0.004446522
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Questions??
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Would you like the good
news?
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Contact Information
Beverly Hoek, RN, CNN
Quality Improvement Director
Quality Insights Renal Network 3
109 South Main Street Suite 21
Cranbury, New Jersey 08512
609-490-0310 ext. 2427
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Tricia Phulchand, RN, BS
Data Manager
Quality Insights Renal Network 3
109 South Main Street Suite 21
Cranbury, New Jersey 08512
609-490-0310 ext. 2422