Quality Insights Renal Network 4 
A Periodic Newsletter from Quality Insights Renal Network 4 | www.qirn4.org
In This Issue
Alerts and Recalls
Quick Links
QIRN 4 Staff
Executive Director
Quality Improvement Director
Quality Improvement Coordinator
Patient Services Director
Patient Services Coordinator
Data Manager
Administrative Assistant
June 2014 
Greetings from QIRN 4
Quality Insights Renal Network 4 (QIRN 4) is committed to providing valuable resources that help improve the quality of renal care in Pennsylvania and Delaware. 
We encourage you to visit our Web site for the most up-to-date information or to contact us with questions, comments or suggestions. 
Your QIRN 4 Team
Quality Incentive Program (QIP)
Did You Know? 

The Centers for Medicare & Medicaid Services (CMS)
administers the End-Stage Renal Disease (ESRD) Quality
Incentive Program (QIP) to promote high-quality services
in outpatient dialysis facilities treating patients with
ESRD. The first of its kind in Medicare, this program
changes the way CMS pays for the treatment of patients
with ESRD by linking a portion of payment directly to
facilities' performance on quality of care measures.

The ESRD QIP will actually reduce payments to dialysis centers that do not meet or exceed performance standards on the following measures.

There are 8 clinical measures: 
  • Hgb > 12 g/dL (hemoglobin)
  • VAT Measure Topic (fistula, catheter)
  • Kt/V Dialysis Adequacy (how well you are dialyzed)
  • NHSN Bloodstream Infection (infection monitoring)
  • Hypercalcemia (excessive calcium)
There are 3 reporting measures:
  • ICH CAHPS (patient satisfaction surveys)
  • Mineral Metabolism (bone health and phosphorus, calcium and PTH)
  • Anemia Management (managing production of red blood cells)
These are the measures that Medicare sees as most important to your health; the important clinical outcomes that drive high-quality care and truly improve the lives
of patients. Meeting and exceeding these performance standards will lead to better health for patients on dialysis and a better quality and experience of care.
Preview Performance Score Reports 
To prepare for the release of the Dialysis Facility Reports (DFRs), Quarterly Dialysis Facility Compare (QDFC) Preview Reports, ESRD QIP Performance Score Reports (PSRs), and ESRD QIP Performance Score Certificates (PSCs) that will be available to facilities on the secure Web site www.DialysisReports.org on July 15, 2014, Master Account Holders (MAH) need to complete the following by July 15, 2014:
  • Login to www.DialysisReports.org with your username (Medicare provider number) and NEW Network-provided password.
  • Reassign user credentials.
Visit the Dialysis Reports Web site or the Network for more information.
ESRD Facilities Honored at QIRN 4 Annual Meeting
QIRN 4 honored several ESRD facilities for their efforts in 2013 at the QIRN 4 Annual Meeting held on May 20, 2014 in Hershey, Pennsylvania.

Award categories included the following:  
  • Top 10 Performing Facilities for Vascular Access 
  • emBRACE Certificates for Patient Engagement Training
  • 5-Diamond Patient Safety Program Completion

Visit the QIRN 4 Web site to see the facilities that were honored. 


2014 Network 4 Goals
The QIRN 4 Medical Review Board has approved goals to focus Network 4 activities in 2014. In addition to these areas, the Medical Review Board will examine other quality indicators (such as patient grievances, hospitalization, mortality, etc.) and conduct improvement initiatives as indicated. All dialysis facilities are expected to meet the requirements of the Performance Year 2014/Payment Year 2016 Quality Incentive Program.
We ask that you attest in the following site after you receive and review these goals by June 30, 2014. If you oversee more than one facility, please add all the CNN numbers in one attestation. The following link will take you to the attestation.



Educational Highlight: Healthcare Worker Fatigue
The Pennsylvania Patient Safety Authority recently published a piece on prevention strategies for healthcare worker fatigue. To learn more about this important topic, visit the organization's Web site here
CROWNWeb 4.4 Released

CROWNWeb 4.4 was released on May 28, 2014. This release features a number of enhancements to the clinical screens in CROWNWeb, which have been designed to streamline the entry of required data. 

Major modifications and enhancements in this release include:  
  • Clinical Save Button: Users can now save clinical entry for a patient at any point prior to submitting and may return later to retrieve and complete the data entry.
  • Streamlined Clinical Data Screens: Many fields on the CROWNWeb clinical screen have been eliminated to reduce burden, increase efficiency, and improve the quality of data submissions.
  • Month-to-Month Data Carry Over: Many clinical fields now carry over from month to month, minimizing the need to re-enter data monthly.
  • "N/A" Check Boxes on Clinical Screen: Users can now indicate that clinical data were "Not Available" for a patient at the individual field level or for all clinical screens for a patient for a single month. 

Online tutorials, help topics, and FAQs can be found on the Project CROWNWeb Web site at www.projectcrownweb.org.  


ESRD Survey Process
Questions continue to arise from providers regarding the ESRD survey process. The Centers for Medicare & Medicaid Services (CMS) has provided some clarification information on its Web site. Providers and the public can access the Dialysis Survey & Certification Web site, which contains the updated version of the ESRD Core Survey Field Manual, surveyor laminates, etc. This site provides basic information related to survey and certification of dialysis facilities, applicable laws and regulations, and provides resources to support and assess compliance with Federal regulations.

NHSN Data Reporting
National Healthcare Safety Network (NHSN) first quarter data will close June 30, 2014

PLEASE NOTE: Any first quarter data that is entered after June 30th will not be accepted by CMS. Only data entered into NHSN by the quarterly deadline is what is reported to CMS. Keep in mind, the Web site does allow for first quarter data to be edited, but any edits performed after June 30th will not be reported to CMS.

Reports should be generated from the NHSN Web site to validate your information and patient data has been correctly entered. Learn more here. 
Sign Up for the ESRD NCC Information Exchange
The End Stage Renal Disease Network Coordinating Center (ESRD NCC) provides centralized coordination and support for the Medicare ESRD Network program. Each month, the ESRD NCC distributes an e-newsletter, known as the Information Exchange, that compiles the most important information from numerous ListServs and publications related to renal health.  
To sign up to receive this informative newsletter, please contact the ESRD NCC at ncc@ncc.esrd.net or visit the ESRD NCC Web site. You can also check the QIRN 4 Web site for updates that include material from the Information Exchange.  

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Quality Insights Renal Network 4
 630 Freedom Business Center, Suite 116
King of Prussia, PA 19406
800-548-9205 (patients only) 
610-783-0374 (fax)
This material was prepared by Quality Insights Renal Network 4 under contract with the Centers for Medicare & Medicaid Services (CMS). The contents do not necessarily reflect CMS policy. 
Publication No. ESRD4-MV-061014 App. 06/14

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