Goals & Recommendations

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS), which oversees the Medicare program, contracts with 18 End Stage Renal Disease (ESRD) Network Organizations throughout the United States to perform oversight activities to ensure appropriateness of services and protection for ESRD patients. Quality Insights Renal Network 3 (QIRN 3) is the ESRD Network contractor selected to serve New Jersey, Puerto Rico and the US Virgin Islands.


REQUIRED NETWORK GOALS FOR ALL FACILITIES:

  • Establish and maintain a quality assessment and performance improvement program that evaluates the care provided and identifies opportunities for and continuously works to improve care delivered.

  • Participate in and meet deadlines for Network led activities. Notify the ESRD Network of key personnel changes.

  • Access the Network ESRD Facility Dashboard and work toward achieving the assigned goals. Topics include:

    • Increase Home Dialysis (Incident (<90 days) and Prevalent transitions (>90 days) from start of dialysis)

    • Increase Transplant (Waiting list and Receiving Transplant)

    • Increase Patient Vaccinations (Influenza and Pneumococcal)

    • Reduce Hospital Admissions and Outpatient Emergency Visits

    • Increase Patient Engagement (Patient-to-Patient Support, Inclusion in QAPI meetings, use of a Life Plan to develop the patient’s plan of care)

    • Meet the CMS goals for Forms Reporting Deadlines (2728 within 45 days, 2746 within 14 days)

RECOMMENDATIONS FOR ALL FACILITIES:

Adequacy

  • Residual renal function should be incorporated into adequacy measures when appropriate.

Data and Reporting Systems

  • Submit data and information timely and accurately as defined by project to the Network and in End Stage Renal Disease Quality Reporting System (EQRS) as is required by law and regulation.

  • Register in NHSN, enroll in the Network 3 group and submit dialysis event data and information timely and accurately on a monthly basis.

Emergency Preparedness

Health Equity

  • Adopt relevant social and structural determinants of health (SDOH) screening tools.

  • Make use of Network tools and training—video-based microlearns, technical assistance, tip sheets—to appropriately screening for, collecting, and reporting SDOH data.

  • Promote language equity and inclusivity by:

    • Implementing a Culturally and Linguistically Appropriate Services (CLAS) Action Plan

    • Providing health literate patient and family materials

Modality Education

  • Assess and refer in a timely manner medically suitable patients to treatment modalities that increase rehabilitation and independence including in-center self-care, home self-care and transplantation.

  • NJ specific- NJ state regulations require a transplant surgeon or designee is a part of the plan of care interdisciplinary team. (N.J.A.C Title 8 Chapter 43 8:43A-24.13 Patient care plan).

Patient Experience of Care

  • Clearly delineate and respect the rights and responsibilities of both the patient, family, significant others and the facility while promoting patient/family centered care and engagement.

  • Actively consult with the Network regarding difficult patient situations prior to any situation escalating to the consideration of an involuntary discharge.

  • Promote patient-appropriate access to in-center dialysis care at the facility level by:

    • Avoiding involuntary discharges (IVDs) and involuntary transfers (IVTs)

    • Assisting in the placement of patients at risk for IVDs or IVTs

Patient Education

  • Make available to patients all Network-provided information on its Quality Improvement Projects, the CMS ESRD QIP, Regional and National profiles of care, the importance of immunization, information on how to access and use CMS Dialysis Facility Compare.

  • Educate patients about all treatment options at initiation of renal replacement therapy annually, and at additional times if indicated by changes in clinical condition.

Patient Engagement

  • Welcome, seek and respect the involvement of patients and, as requested, their family in all aspects of life and medical care planning to enhance shared decision making. Patients should have the opportunity to define who they consider members of their family.

  • Integrate patient and/or an active family member into the Interdisciplinary Team’s (IDT) monthly Quality Assessment and Performance Improvement (QAPI) meetings.

  • Actively promote the Network’s Patient to Patient Mentoring Program to foster connection and support among patients.

  • Encourage patients to become Subject Matter Experts (SMEs) to the Network to provide their patient perspective in quality improvement activities.

Patient Safety

  • All facilities are urged to embrace a “culture of safety” and initiate specific measures to enhance safety, and prevent/reduce medical errors, such as:

    • Use a standardized abbreviation list

    • Use stickers to warn of allergies, of like or similar names and anticoagulation therapy

    • Post a list of drug dialyze‐ability, or drugs to avoid during dialysis

    • Track adverse events/incidents

    • Identify and track healthcare‐associated infections (HAIs) that develop during the course of care in the facility, and report such infections in NHSN

    • Identify, track and use preventative measures against central line‐associated blood stream infections (CLABSIs) that include:

      • Routine review of central venous line care procedures with healthcare workers and patients

      • Removal of non‐essential central venous lines

  • All facilities are encouraged to participate in the Quality Insights 5‐Diamond Patient Safety Program

  • Follow the CDC’s Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients.

Centers for Medicare and Medicaid (CMS) End Stage Renal Disease (ESRD) Quality Incentive Program (QIP)
CfC Interpretative Guidelines, § 494.110 Condition: Quality assessment and performance improvement (V628) states, Where minimum outcome values have been determined, facilities are expected to provide care directed at achievement of at least the minimum outcome value by all patients.
Facilities that have achieved the minimum goals shall strive to meet or exceed the top 10% goals.

Source: Federal Register
* On these measures, a lower rate indicates better performance.
**Minimum Goal- This is the CMS ESRD QIP Final PY 2027 Performance Standard, which is the 50th percentile of performance rates nationally Data sources: VAT measure: 2023 EQRS; SRR, SHR, STrR: 2023 Medicare claims; Kt/V: 2023 EQRS and 2023 Medicare claims; NHSN: 2023 CDC; ICH CAHPS: CMS 2023; PPPW: 2023 EQRS and 2023 Organ Procurement and Transplantation Network (OPTN); Clinical Depression: 2023 EQRS.
***Top 10% Nationwide- This is the CMS ESRD QIP Final PY 2027 Benchmark, which is the 90th percentile (Best 10% of units) of performance rates nationally during CY 2023. Facilities that meet or exceed these rates will likely earn the full points for the specified measure.
ᵃ Rate calculated as a percentage of hospital discharges. ᵇ Rate per 100 patient-years.

 

Resources

 

 

Appendix 1: Tables extract from the Federal Register is included as references for the measure reporting requirements.

Appendix 2: Tables extract from the Federal Register is included as reference for the eligibility requirements for scoring on ESRD QIP measures.


MRB approved: 02/12/25

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