Quality Improvement
ESRD Core Survey Updates
The Centers for Medicare and Medicaid Services (CMS) updates the ESRD Core Survey materials on a yearly basis. The CMS calendar runs from October 1 of one year through September 30 of the following year, with materials updated accordingly. The most recent Core Survey manual is version 1.8, and is available for download from the CMS Website at:
We encourage you to download the most recent materials on a yearly basis to ensure you are keeping up with current survey process and requirements.
The Network also recommends that you pay particular attention to the Core Survey Data Worksheet. This worksheet provides guidance about materials and reports that must be prepared and available to surveyors within 3 hours of their arrival at your facility for survey. If you have any questions about this process, please reach out to your local state health department for additional guidance.
Reducing Hepatitis C Transmission During Hemodialysis Treatments
The Centers for Disease Control and Prevention (CDC) released recommendations for reducing transmission of the Hepatitis C virus (HCV) during in-center hemodialysis treatment.
According to CDC, HCV starts as an acute infection, and approximately 75 - 85% of people who become infected develop a lifelong, chronic infection which can lead to severe liver disease and liver cancer. Curative therapy is now available, even for some patients with end stage renal disease. Because HCV is transmitted through percutaneous blood exposure and can survive in the environment for extended periods of time, lapses in infection control practices at dialysis facilities could expose patients to HCV.

For more information, tools, and resources, please visit the CDC Website.
NHSN Training Course
The Centers for Disease Control and Prevention (CDC) and The National Healthcare Safety Network (NHSN) invites you to virtually attend, via webstream, the NHSN training course on "Applying the 2016 Changes to Accurately Report HAI's," to be held February 29 - March 4, 2016 at the CDC Global Communications Center in Atlanta, GA.
This training is intended for infection preventionists, and staff from Quality Improvement organizations, Quality Improvement Networks, Health Engagement Networks, State Health Departments, and others interested in learning more about NHSN surveillance. Topics will include CMS reporting, definition, and protocol clarification for catheter-associated urinary tract infection (CAUTI) and central line-associated bloodstream infection (CLABSI) C.diff and MRSA events, and Antibiotic Stewardship. Subject Matter Experts will provide interactive case studies for each infection/event type.
Live webstreaming begins February 29, 2016 at 1:30 PM EST. The speakers agenda and intructions on how to view the webstream are posted here. The sessions will be recorded and archived on the NHSN website for future viewing.

Patient Services
Reviewing Grievance Logs
In 2016, the Network is working on a CMS-driven quality improvement activity (QIA) to review and foster the development of robust and complete grievance logs at the facility level. By  improving the consistency of these logs, facility staff can improve provider/patient relationships and be better prepared for a state survey. 
 For more information about the Grievance QIA please visit our website.
Webinar Tomorrow!
On February 23, 2016 the IPRO ESRD Network Program will be hosting a Webinar to provide a brief overview and review of facility Grievance Logs and provide information about the Grievance project for 2016.
Registration is now available.

CMS Required Depression Screening
Beth Witten, MSW, ACSW, LSCSW, has written a comprehensive article discussing depression screening requirements.  Excerpt: Dialysis clinics must screen eligible dialyzers age 12 or older and those who have been on dialysis at least 90 days for clinical depression (both as of October 31, 2016 before February 1, 2017) using a standardized screener once between January 1, 2016 and before February 1, 2017. There are several standardized screeners, but two that are validated for all ages include the PRIME MD PHQ-2 and the CES-D. Facilities that opened before July 1, 2016 and those that treat more than 11 dialyzers will get a score for depression screening and follow-up that will be used with other QIP measures to determine the facility's payment for 2018.
If you have questions about this new requirement, please see the article on the Home Dialysis Central website , the CMS Technical Specifications (page 22) or contact Brittney Jackson, Patient Services Director by calling (203) 285-1213.
Data Management
Extending the Compliance Date for Posting Performance Score Certificates
During the PY 2019 Final Rule National Provider Call on January 19, 2016, CMS set the deadline at February 1, 2016, for facilities to post their PSCs in a prominent patient area. Subsequently, CMS has learned that facilities may have experienced obstacles in accessing their accounts on QualityNet.org and retrieving their reporting documents. In light of those developments, CMS has updated the deadline for facilities to post their PSCs to February 22, 2016.

Facilities must post their ESRD Quality Incentive Program (QIP) Performance Score Certificates (PSC) in both English and Spanish for Payment Year (PY) 2016.

Understanding the 2016 Calendar Year QIP Measures
Please see the CMS End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) Payment Year (PY) 2018 Final Measure Technical Specifications to review the ESRD QIP technical specifications for all 2016 calendar year measures for:
Infection Monitoring: NHSN BSI Clinical Measure; ICHCAHPS Clinical Measure; Standardized Readmission Ratio (SRR) Clinical Measure; Standardized Transfusion Ratio (STrR) Clinical Measure; Kt/V Dialysis Adequacy Measures; Vascular Access Type Measures; Hypercalcemia Clinical Measure; Mineral Metabolism Reporting Measure; Anemia Management Reporting Measure; Pain Assessment and Follow-Up Reporting Measure; Clinical Depression Screening and Follow-Up Reporting Measure; and NHSN Healthcare Personnel Influenza Vaccination Reporting Measure.
Other Important Updates
ESRD News and Alerts
FDA Safety Alert: Baxter International Inc. of Deerfield, Illinois, is voluntarily recalling one lot of 0.9% Sodium Chloride Irrigation, USP, 500 mL Plastic Pour Bottle solution to the hospital/user level. This product is being recalled due to a customer complaint prior to use for the presence of particulate matter, identified as an insect. Sodium Chloride Irrigation solution with foreign material contamination potentially could result in a series of complications dependent in which anatomic location the irrigation is used, which could include inflammatory reaction, foreign body reaction, and infection which could be life-threatening. For more information please refer to the Network Website.
2016-2020 Facility Agreements- Due Now!
2016-2020 Network Facility Agreements have been distributed to all Network facilities and transplant centers. We have utilized a new application called DocuSign to obtain electronic signatures from the facility Medical Director and the Facility Administrator. The Network used CROWNWeb facility personnel information to obtain the appropriate names and e-mail addresses for the individuals who need to sign the agreements.

If you believe you should have received an agreement and did not, or the agreement was not sent to the appropriate individual, please contact Jenna Vonaa at (203) 285-1222.
We have also asked for a Network Council Representative as well as a Patient Advisory Committee (PAC) Representative to be nominated by your facility. The Network Council Representative is an elected facility staff member who will serve as a point of contact person and a liaison between the facility and the Network. The PAC Representative is a patient that the facility would like to nominate who could serve as a peer mentor for other patients and represent your facility during PAC conference calls and works closely with the Network Community Outreach Coordinator. For more information about these roles, please refer to our website

For detailed (step-by-step) instructions on how to complete the electronic signatures using DocuSign, please click here.

Upcoming Meeting & Events
Tuesday, February 23, 2016- Improving the Grievance Process Webinar hosted by IPRO ESRD Network Program
Thursday, March 10, 2016- National Kidney Foundation (NKF) KEEP Healthy Event, 12:00-4:00 pm One City Hall Square, Boston, MA


Wednesday, April 27- May 1, 2016- The National Kidney Foundation (NKF) 2016 Spring Clinical Meetings at the Hynes Convention Center in Boston, MA.
Sunday, May 1- May 4, 2016- ANNA National Symposium, Nephrology Nursing event at the Marriot Louisville & Kentucky International Convention Center in Louisville, KY

IPRO End-Stage Renal Disease Network of New England, the ESRD Organization for Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont, prepared this material under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMS Contract Number: HHSM-500-2016-00019C.

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