Presentation on theme: "Confidential and Proprietary ANNA Chapter 126 March 26, 2015 Tricia Phulchand, RN, BS Data Manager Quality Insights Renal Network 3 CROWNWeb Data Validation."— Presentation transcript:
Confidential and Proprietary ANNA Chapter 126 March 26, 2015 Tricia Phulchand, RN, BS Data Manager Quality Insights Renal Network 3 CROWNWeb Data Validation Project What’s new in Network reporting? Knowing your DFR
Confidential and Proprietary What is CrownWeb (CW)? Consolidated Renal Operations in a Web-Enabled Network
Confidential and Proprietary 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.
Confidential and Proprietary 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
Confidential and Proprietary Purpose of Validation Improve reporting Improved training Receive input from users Identify workflow issues
Confidential and Proprietary 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
Confidential and Proprietary 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
Confidential and Proprietary Contracted Company Healthcare Management Solutions, LLC (HMS) Letter will come from this company to facility DON’T THROW IT AWAY!!
Confidential and Proprietary 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)
Confidential and Proprietary Sample Letter Requested April, 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
Confidential and Proprietary Example of HMS data request letters from 2013:
Confidential and Proprietary 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
Confidential and Proprietary 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
Confidential and Proprietary 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
Confidential and Proprietary 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
Confidential and Proprietary Progress Notes - Continued Doppler Doppler frequency Intra-access flow Intra-access flow frequency Prescription change after adequacy measurement
Confidential and Proprietary 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
Confidential and Proprietary 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
Confidential and Proprietary Treatment Flow Sheets Patient’s identifiable information Pre and post weight Pre and post BP Initial assessment Prescribed treatment Administered medications
Confidential and Proprietary 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
Confidential and Proprietary 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
Confidential and Proprietary 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)
Confidential and Proprietary Option 1 PDF Submission –On CD, DVD or flash drive Mail in tamper-evident packaging Return receipt Mail to address in mailing
Confidential and Proprietary 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
Confidential and Proprietary 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.
Confidential and Proprietary Option 2 DDDDo Not Leave Fax Machine Unattended WW hen 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.
Confidential and Proprietary Option 3 Paper Submission MUST BE SHIPPED TO HMS BY USPS CERTIFIED MAIL ONLY IN TAMPER-EVIDENT PACKAGING WITH RETURN RECEIPT
Confidential and Proprietary 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
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.
Confidential and Proprietary Facility Vascular Access Summary Report
Confidential and Proprietary Example of New Report Showing Quarterly Goals
Confidential and Proprietary Patient Specific Report
Confidential and Proprietary 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"
Confidential and Proprietary 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.
Confidential and Proprietary 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.
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 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