confidential and proprietary anna chapter 126 march 26, 2015 tricia phulchand, rn, bs data manager...

Confidential and Proprietary

ANNA Chapter 126

March 26, 2015

Tricia Phulchand, RN, BS

Data Manager

Quality Insights Renal Network 3

CROWNWeb Data Validation ProjectWhat’s new in Network reporting?

Knowing your DFR


Spring is Here???


What is CrownWeb (CW)?

Consolidated Renal Operations in a

Web-Enabled Network


CW CW was developed to be the next generation in data-

collection 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 data-management system that meets the data submission needs of dialysis facilities, while adhering to requirements set for federal information systems while supporting CMS goals.


A Simple Chart


DO NOT PANIC

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

CMS Data Validation Project


Purpose of Validation

Improve reporting Improved training Receive input from users Identify workflow issues


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


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


Contracted Company

Healthcare Management Solutions, LLC (HMS) Letter will come from this company to facility

DON’T THROW IT AWAY!!


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)


Sample Letter RequestedApril, May and June 2014

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


Example of HMS data request letters from 2013:


Requested Policies

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


Calculation Methods/Processes

Albumin– BCG/ BCP

Kt/V– UKM– Daugirdas II– Depner– Derived from URR, no

patient weight

V calculation for PD– % body weight– Hume– Watson– Other

Surface area PD– Dubois & Dubois– Other

You may have to call your lab to find these answers


MD Orders

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


Progress Notes -legible, date and time

Treatment Start Date Kt/V (HD) Kt/V HD collection date Date access type

changed

Access physical exam Access physical exam

frequency Static venous pressure Static venous pressure

frequency


Progress Notes - Continued

Doppler Doppler frequency Intra-access flow Intra-access flow frequency Prescription change after adequacy measurement


Laboratory Report

Kt/V HD Kt/V date Kt/V Method Hgb and Hgb date Ferritin and date TSAT and date Retic Hgb (CHr) and date

Phosphorus and date Corrected Calcium and

date Uncorrected Calcium and

date Albumin, range and date Albumin method


Laboratory Report

Date PD adequacy measurement Weekly Kt/V PD Kt/V PD method Body surface area method Residual renal function assessed in calculating

Kt/V


Treatment Flow Sheets

Patient’s identifiable information Pre and post weight Pre and post BP Initial assessment Prescribed treatment Administered medications


Treatment Flow Sheets

Modality Primary type of treatment Treatment start date Sessions per week ESA prescribed and Lab

work

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 orderDate ESA prescription changed

Date IV iron prescription changed


Secure Submission Requirements

3 Options


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)


Option 1

PDF Submission– On CD, DVD or flash drive

Mail in tamper-evident packaging Return receipt Mail to address in mailing


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


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.


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.


Option 3

Paper Submission

MUST BE SHIPPED TO HMS BY

USPS CERTIFIED MAIL ONLY IN TAMPER-EVIDENT PACKAGING WITH

RETURN RECEIPT


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


Questions?


QIRN3’s Data Sources

Vascular Access Reports Annual and Quarterly

Dialysis Facility Reports Quality Incentive

Program Reports CROWNWeb data Grievances

NHSN Reports New Clinical Data

Reports from CW DOH Federal survey

results and communication

On-site visits

We are able to pull data from multiple sources and create NW reports.


Facility Vascular Access Summary Report


Example of New Report Showing Quarterly Goals


Patient Specific Report


Not Reported in CW/ Later Entered- no AVGs maturing


Vascular Access Trend Report

INCREASING

STAGNANT


Quality Incentive Certificate


2015 QIP Certificate


A Closer look…


5 Star Rating System


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"


5 Star Rating


Purpose of the ReportThe 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 6,371reports that have been distributed to ESRD providers in the U.S.


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 four-year 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.


Coefficient WeightInability to ambulate 0.371680375Malignant neoplasm, Cancer 0.318879608Drug dependence 0.310703703Congestive heart failure 0.293942558Inability to transfer 0.285321945Chronic obstructive pulmonary disease 0.255658337Alcohol dependence 0.238079181Other cardiac disease 0.158233847Tobacco use (current smoker) 0.137818834Diabetes (currently on insulin) 0.131365189Peripheral vascular disease 0.110387762Cerebrovascular disease 0.081666976Atherosclerotic heart disease 0.037368308Diabetes 0.004446522


Questions??


Would you like the good news?


Contact Information

Beverly Hoek, RN, CNN

Quality Improvement Director


109 South Main Street Suite 21

Cranbury, New Jersey 08512

609-490-0310 ext. 2427

Tricia Phulchand, RN, BS

Data Manager


109 South Main Street Suite 21

Cranbury, New Jersey 08512

609-490-0310 ext. 2422

confidential and proprietary anna chapter 126 march 26, 2015 tricia phulchand, rn, bs data manager...

Documents

letter slide

proprietary cw cw

proprietary spring

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proprietary sample letter

proprietary anna chapter

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