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NHSN and CMS End Stage Renal Dialysis Quality Incentive Program (ESRD QIP) Rule
Reporting
- Which types of dialysis facilities are required to participate in the Centers for Medicare and Medicaid Services (CMS) End Stage Renal Disease (ESRD) Quality Incentive Program (QIP) National Healthcare Safety Network (NHSN) Dialysis Event Reporting Measures?
- What do I have to report to NHSN for the CMS ESRD QIP rule?
- What do I need to do in order to report?
- How does CMS score the ESRD QIP NHSN Reporting Measure?
NHSN Enrollment and Training
- When should we start enrolling our facility into NHSN to meet reporting deadlines for the CMS ESRD QIP rule?
- Where do I start?
- What is the required training to get started in NHSN?
- My hospital-based facility has more than one associated CMS Certification Number (CCN) (i.e., a hospital CCN and a dialysis CCN). Which CCN should I use for my facility in NHSN?
- My dialysis facility is already enrolled and reporting, is there anything I need to do?
- If outpatient dialysis services are contracted, who is responsible for reporting to NHSN?
- How should NHSN user roles be assigned given challenges related to staff turnover?
- What data will CDC share with CMS about dialysis facilities participating in Dialysis Event surveillance?
- What is the Bloodstream Infection (BSI) Standardized Infection Ratio?
General
Reporting
Which types of dialysis facilities are required to participate in the Centers for Medicare and Medicaid Services (CMS) End Stage Renal Disease (ESRD) Quality Incentive Program (QIP) National Healthcare Safety Network (NHSN) Measures?
The CMS ESRD QIP NHSN reporting measure only applies to facilities that treat hemodialysis patients in-center. Facilities treating 10 or fewer patients are excluded. For purposes of the NHSN Dialysis Event reporting measure, CMS determines whether a facility meets these criteria by referencing the facility’s information in CMS data sources (that is, SIMS and CROWNWeb). For more information, please see the current CMS ESRD QIP rule. No patient census or modality eligibility requirements exist for the CMS ESRD QIP NHSN Healthcare Personnel Influenza Vaccination reporting measure.
What do I have to report to NHSN for the CMS ESRD QIP rule?
Facilities reporting to NHSN for the CMS ESRD QIP rule must follow NHSN Dialysis Event Protocol. Reporting Deadlines are quarterly and only change if they occur on a holiday or week end where the deadline would be the following business day.
- January – March data are due on or before June 30.
- April – June data are due on or before September 30.
- July – September data are due on or before December 31.
- October – December data are due on or before March 31.
CDC has published Recommended Interventions for Bloodstream Infection (BSI) Prevention in Dialysis. Facilities are encouraged, though not required, to adopt the nine interventions in an effort to help prevent infections.
What do I need to do in order to report?
In order for a dialysis facility’s data to be reported to NHSN and sent to CMS, a facility must:
- Complete required training
- Submit an annual NHSN Outpatient Dialysis Center Practices Survey
- Enroll the dialysis facility in NHSN as an ‘AMB-HEMO – Hemodialysis Center’ facility type.
- Input a correct CMS Certification Number (CCN) into NHSN (during enrollment or afterward, as needed).
- Activate the Dialysis Component and Healthcare Personnel Safety Component (during enrollment or following facility activation).
- Report data following the NHSN Dialysis Event Protocol [PDF – 245KB] and the Healthcare Personnel Vaccination Module: Influenza Vaccination Summary Protocol [PDF – 468KB].
If you are already participating in NHSN, you can verify both facility type and CCN within NHSN by clicking on “Facility” and then “Facility Info” on the NHSN navigation bar and reviewing the “Facility Information” section.
Measurement is at the individual facility level; at least one staff member at each facility must be trained in and knowledgeable of how to report dialysis event data to NHSN. At least one staff member at the facility should have access to NHSN, even if data are not being manually submitted to NHSN by facility staff.
How does CMS score the ESRD QIP NHSN Measures?
Facilities must complete training and enroll in NHSN prior to reporting data to fulfill the requirements of these measures.
CMS scoring criteria are outlined in the final CMS ESRD QIP Rules:
- For Calendar Year 2014 (Payment Year 2016) see the Federal Register, volume 78, number 231, section II.7.c, page 72213.
- For Calendar Year 2015 (Payment Year 2017) see the Federal Register, volume 79, number 215, section III.D, page 66166.
- For Calendar Year 2016 (Payment Year 2018) see the Federal Register, volume 79, number 215, section III.D, F, pages 66166 and 66206
CDC expects that the facility has done adequate data validation to ensure data being reported are complete and correct by comparing dialysis event data collected manually to the dialysis event data that has been reported to NHSN. A facility-based NHSN user is expected to have access to NHSN and continue to review the data in NHSN on an ongoing basis to verify data reported are complete and correct. For assistance with performing data quality evaluation, see the NHSN Dialysis Event Surveillance & Reporting Data Quality Evaluation – Project Implementation Guide April 2014 [PDF – 187KB] and the 3 Steps to Review NHSN Dialysis Event Surveillance Data January 2017 [PDF – 286KB] document.
NHSN Enrollment and Training
When should we start enrolling our facility into NHSN to meet reporting deadlines for the CMS ESRD QIP rule?
Enrollment is a one-time process; once your facility is enrolled in NHSN, no additional enrollment steps are required to continue reporting indefinitely.
Facilities should begin enrollment as early as possible to ensure they have access to the system well before the data reporting deadlines for which they are eligible. An 75.104 Outpatient Dialysis Center Practices Survey [PDF – 96KB] is required as part of the enrollment process. This survey includes questions that are specific to the first week of February, so users are strongly encouraged to collect these data in February, regardless of when during the year they plan to initiate NHSN enrollment.
NHSN enrollment consists of several steps. Although each facility’s timeline is different, allow at least 4-6 weeks to complete enrollment. Facilities that belong to a corporate dialysis chain are encouraged to contact their corporate headquarters to determine if an enrollment plan has already been established for their facility to prevent duplicate enrollments in the system. Facilities may also contact their ESRD network for assistance.
Where do I start?
Begin by completing the required training on the Outpatient Dialysis Facility Training page. Once you have completed your required training, you can enroll your facility in NHSN or if your facility is already enrolled, ask a user with administrator rights to add you as a user [PDF – 245KB] for the facility.
What is the required training to get started in NHSN?
Required training materials are listed on the Dialysis Event website. There are three main areas of training for new users:
- NHSN Enrollment for Outpatient Dialysis Facilities
- Training format: watch the 23 minute enrollment video *
- Required for: users who are enrolling one or more facilities
- * Note: Enrollment Step 3 has changed. User access to NHSN is transitioning to a new system, Secure Access Management Services (SAMS). Read more about NHSN and SAMS .
- NHSN Set-up for Outpatient Dialysis Facilities
- Training format: watch the 13 minute set-up video
- Required for: users who have enrolled one or more facilities and for other users assigned administrator user rights
- Dialysis Event Surveillance Protocol
- Training format:
- Complete the self-paced, computer-based NHSN Dialysis Event Surveillance training
- Complete the free Continuing Education (optional)
- Read the Dialysis Event Protocol – English [PDF – 260KB]
- Review the data collection forms
- Complete the self-paced, computer-based NHSN Dialysis Event Surveillance training
- Required for: all dialysis facility users with access to the Dialysis Component, and for non-users who are involved in data collection
- Training format:
- Healthcare Personnel Safety Component: Influenza Vaccination Summary Protocol
- Training format:
- Read the Healthcare Personnel Vaccination Module: Influenza Vaccination Summary Protocol [PDF – 468KB]
- Review the data collection forms
- Healthcare Personnel Safety Monthly Reporting Plan Form
- Healthcare Personnel Influenza Vaccination Summary Form
- Required for: all dialysis facility users who have access to the Healthcare Personnel Safety Component, and for non-users who are involved in data collection
- Training format:
Users should complete training before getting started in NHSN. Each user’s training completion date is required prior to gaining access to the system. The training completion date is the date the user completed their required training, as listed above.
My hospital-based facility has more than one associated CMS Certification Number (CCN) (i.e., a hospital CCN and a dialysis CCN). Which CCN should I use for my facility in NHSN?
Hospital-based facilities with more than one CCN may register under either their hospital CCN or their dialysis CCN and receive credit for ESRD QIP scoring. Each dialysis facility should register in NHSN only once, but can use either CCN.
My dialysis facility is already enrolled and reporting, is there anything I need to do?
Yes, if your facility is already enrolled and reporting, please verify:
- Your facility information: from the NHSN navigation bar, select “Facility” and then “Facility Info” and check the facility’s CMS Certification Number (CCN) is correct. If it is not correct, revise it and save changes on this screen.
- Your facility is reporting data according to the Dialysis Event Protocol [PDF – 245 KB] and Healthcare Personnel Vaccination Module: Influenza Vaccination Summary Protocol [PDF – 468KB] . This requires all persons involved in data collection and reporting understand the protocol and surveillance definitions.
If outpatient dialysis services are contracted, who is responsible for reporting to NHSN?
It is up to the organization/dialysis facility to decide whether or not they are interested in participating in NHSN reporting. If they decide to participate, then they must also decide who will be responsible for tracking and entering the required data to NHSN. The person(s) conducting this data collection and data reporting are responsible for completing the training and following the reporting requirements as specified in the NHSN Protocols.
How should NHSN user roles be assigned given challenges related to staff turnover?
Each NHSN facility should have at least two users with administrator rights to simplify issues related to staff turnover. If the NHSN Facility Administrator will be leaving a facility, he or she needs to reassign their NHSN Facility Administrator role to another NHSN user before his or her departure. All NHSN users who no longer work for a specific facility should be deactivated immediately.
If your facility is enrolled, but does not have current staff members with access to NHSN, contact the NHSN Helpdesk at nhsn@cdc.gov for assistance.
What data will CDC share with CMS about dialysis facilities participating in Dialysis Event surveillance?
CDC uses a list of ESRD CMS Certification Numbers (CCNs) provided by CMS to confirm whether a facility with a corresponding CCN is enrolled in NHSN. Specific NHSN Dialysis Event data shared with CMS has varied by performance year:
- Calendar year 2014: number of months of complete data reported to NHSN according to the Dialysis Event Protocol for each quarter, the data used to calculate the NHSN Bloodstream Infection (BSI) Standardized Infection Ratio (SIR), as well as the final BSI SIR and 95% upper and lower confidence intervals.
- Calendar year 2015: number of months of complete data reported to NHSN according to the Dialysis Event Protocol for each quarter, the data used to calculate the NHSN Standardized Infection Ratio (SIR), as well as the final BSI SIR and 95% upper and lower confidence intervals.
What is the Bloodstream Infection (BSI) Standardized Infection Ratio?
For performance year 2014, CMS advanced the QIP rule from an NHSN reporting measure to a clinical measure. For 2014, the Standardized Infection Ratio (SIR) will be used to assess facility bloodstream infection among hemodialysis outpatients. The SIR is a risk-adjusted summary measure that compares the observed number of infections to the predicted number of infections based on NHSN aggregate data from a standard population.
- SIR greater than 1: the facility reported more BSI than predicted.
- SIR equal to 1: indicates the facility reported the same number of BSI as predicted.
- SIR less than 1: indicates the facility reported fewer BSI than predicted.
- The SIR adjusts for vascular access type distribution in the facility.
General
Who do I contact with CMS ESRD QIP rule questions that are not related to NHSN?
