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Confidential and Proprietary ANNA Chapter 126 March 26, 2015 Tricia Phulchand, RN, BS Data Manager Quality Insights Renal Network 3 CROWNWeb Data Validation.

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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:

1 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

2 Confidential and Proprietary Spring is Here???

3 Confidential and Proprietary What is CrownWeb (CW)? Consolidated Renal Operations in a Web-Enabled Network

4 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.

5 Confidential and Proprietary A Simple Chart

6 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

7 Confidential and Proprietary Purpose of Validation  Improve reporting  Improved training  Receive input from users  Identify workflow issues

8 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

9 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

10 Confidential and Proprietary Contracted Company  Healthcare Management Solutions, LLC (HMS)  Letter will come from this company to facility DON’T THROW IT AWAY!!

11 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)

12 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

13 Confidential and Proprietary Example of HMS data request letters from 2013:

14 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

15 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

16 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

17 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

18 Confidential and Proprietary Progress Notes - Continued  Doppler  Doppler frequency  Intra-access flow  Intra-access flow frequency  Prescription change after adequacy measurement

19 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

20 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

21 Confidential and Proprietary Treatment Flow Sheets  Patient’s identifiable information  Pre and post weight  Pre and post BP  Initial assessment  Prescribed treatment  Administered medications

22 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

23 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

24 Confidential and Proprietary Secure Submission Requirements 3 Options

25 Confidential and Proprietary

26 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)

27 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

28 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

29 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.

30 Confidential and Proprietary Option 2 DDDDo Not Leave Fax Machine Unattended WW 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.


32 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

33 Confidential and Proprietary Questions?

34 Confidential and Proprietary

35 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.

36 Confidential and Proprietary Facility Vascular Access Summary Report

37 Confidential and Proprietary Example of New Report Showing Quarterly Goals

38 Confidential and Proprietary Patient Specific Report

39 Confidential and Proprietary


41 Not Reported in CW/ Later Entered- no AVGs maturing

42 Confidential and Proprietary


44 Confidential and Proprietary Quality Incentive Certificate

45 Confidential and Proprietary 2015 QIP Certificate

46 Confidential and Proprietary A Closer look…

47 Confidential and Proprietary

48 5 Star Rating System

49 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"

50 Confidential and Proprietary

51 5 Star Rating

52 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.

53 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.

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57 CoefficientWeight Inability to ambulate0.371680375 Malignant neoplasm, Cancer0.318879608 Drug dependence0.310703703 Congestive heart failure0.293942558 Inability to transfer0.285321945 Chronic obstructive pulmonary disease0.255658337 Alcohol dependence0.238079181 Other cardiac disease0.158233847 Tobacco use (current smoker)0.137818834 Diabetes (currently on insulin)0.131365189 Peripheral vascular disease0.110387762 Cerebrovascular disease0.081666976 Atherosclerotic heart disease0.037368308 Diabetes0.004446522

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61 Questions??

62 Confidential and Proprietary Would you like the good news?

63 Confidential and Proprietary

64 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

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