Update: CMS Surveys and the QIP Measures What’s Up With That? Update: CMS Surveys and the QIP Measures Glenda M. Payne, RN, MS, CNN Director of Clinical Services Nephrology Clinical Solutions

Take-Aways Recognize the current focus of the ESRD survey process List the top ten cited deficiencies for 2014 Compare and contrast frequently cited deficiencies for complaint surveys vs. standard surveys Describe changes to the QIP measures for 2015-2017 Identify actions to prepare for the 2016 performance period

CMS: Core Survey Process All ESRD surveys are done using the Core Survey Process Focus: Patient safety and Facility responsibility for continuous quality improvement

Culture of Safety: Primary Components A robust and proactive system for reporting and addressing errors Open blame-free communication between all levels of staff and patients Communication of clear expectations to staff Complete staff and patient engagement All are committed to identifying and mitigating any risks to patients CMS Core Survey Field Manual

CMS Core Survey: Culture of Safety Facility staff are expected to: MONITOR the safety and effectiveness of the care delivered and facility operations RECOGNIZE risks and opportunities for improvement ADDRESS those risks and opportunities Patient & Facility-level data/activities are reviewed for a Culture of Safety approach Or maybe the comments in the reverse order? CMS Core Survey Field Manual

Preliminary Citation Patterns V Tag % Change: Core Vs. Trad. Comment V113-Hand hygiene 35% On IC ✔lists V122-Disinfect stat. 15% On IC ✔list V141-CVC care 83% V143-Aseptic meds 61% On IC ✔list V550-AVF 24% V628-QAPI actions 184% On QAPI review tool V543-Fluid management 31% Focus Core survey V544-Adequacy 43% V260-Audit technical procedures 55% On Core tools V715-all adhere/ P&P 39% Catch-all tag Source: CMS presentation NKF, 4/2015

Frequently Cited Deficiencies: 2014 Standard Surveys - 1928 surveys/6414 Active Providers # V-Tag Tag Description # Citations % Surveys Cited 1 V113 IC-Wear Gloves/Hand Hygiene 648 33.6% 2 V122 IC-Clean, disinfect surfaces & equipment/written protocols 581 30.1% 3 V543 POC-Manage volume status 323 16.8% 4 V403 PE-Equipment maintenance- manufacturer’s DFU 307 15.9% 5 V147 IC-Staff education re catheters/catheter care 269 14.0%

Frequently Cited Deficiencies: 2014 Standard Surveys - 1928 surveys/6414 Active Providers # V-Tag Tag Description # Citations % Surveys Cited 6 V715 MD Resp- Ensure all adhere to P&P 264 13.7% 7 V143 IC-Aseptic techniques for IV meds 263 13.6% 8 V116 IC- Items taken to station disposed/dedicated or disinfected 257 13.3% 9 V115 IC- Wear gowns, shields, masks; staff not eat/drink in treatment area 254 13.2% 10 V407 PE- Hemodialysis patients in view during treatments 223 11.5%

Frequently Cited Deficiencies: 2014 COMPLAINT Surveys - 794 surveys /6414 Active Providers # V-Tag Tag Description # Citations % Surveys Cited 1 V113 IC - Wear gloves/hand hygiene 42 5.3% 2 V122 IC - Clean, disinfect surfaces and equipment /written protocols 39 4.9% 3 V715 MD Resp - Ensure all adhere to P&P 31 3.9% 4 V726 Medical Records – Complete, accurate, accessible 28 3.5% 5 V111 IC - Sanitary environment 27 3.4%

Frequently Cited Deficiencies: 2014 COMPLAINT Surveys - 794 surveys/ 6414 Active Providers # V-Tag Tag Description # Citations % Surveys Cited 6 V543 POC - Manage volume status 23 2.9% 7 V750 Condition: Governance 21 2.6% 8 V452 Patient rights – Respect & dignity 9 V401 PE – Safe, functional, comfortable environment 19 2.4% 10 V407 PE – Hemodialysis patients in view during treatment 18 2.3%

Standard Surveys Complaint Surveys 1 V113-IC (Hand hygiene/gloves) V113- IC (same) 2 V122-IC (Clean equipment/surfaces) V122-IC (same) 3 V543-POC (Manage volume status) V715- (# 6 in Standard survey) 4 V403-PE (Equipment maintenance) V726-Medical records: (Not in top 10 for Standard) 5 V147-IC (Catheter care) V111-IC (Not in top 10 for Standard) 6 V715-MD Resp (All adhere to P&P) V543-POC (#3 in Standard survey) 7 V143-IC (Aseptic technique for IV meds) V750- CONDITION-Governance (not in top 10 for Standard) 8 V116-IC (Items taken to station = D/D/D) V452- Patient Rights—Respect & Dignity (not in top 10 for Standard) 9 V115-IC (Wear PPE) V401-PE- (Not in top 10 for Standard) 10 V407-PE (HD patients in view [access uncovered]) V407-PE (same)

Top Condition Level Citations: 2014 Standard Surveys Condition of Infection Control #23 in frequency of citation 135 citations in 1928 surveys Cited in 7% of the Standard surveys done in 2014 Complaint Surveys Condition of Governance # 7 in frequency of citation 21 citations in 794 surveys Cited in 2.6% of the Compliant surveys done in 2014

Recent Change to Surveyor Guidance June 12, 2015 Survey & Certification Letter 15-41-ESRD: “Surveyor Guidance For Approval Of Home Dialysis Modalities” Must have at least one patient on census In the process of being trained Or has been trained by the facility IDT For EACH home dialysis modality requested Will not accept transfers of patients already trained as meeting this requirement “Borrowing” qualified home dialysis staff from another certified facility for initial approval of a home dialysis program will not be accepted.

Questions So Far?

What’s Up with the QIP Measures?

QIP Measure Process CMS goal for ESRD QIP measures: Promote high-quality care Strengthen the goals of the National Quality Strategy MIPPA requirement: Use National Quality Forum (NQF) endorsed measures when available CMS may add measures if NQF endorsed measures do not exist or are not sufficient for the topic area The law requires measures on anemia & adequacy

Two Kinds of Measures Clinical Measures: Reporting Measures: Your facility gets a score Target scores include: Thresholds (15th percentile) Performance standards (Median) Benchmarks (90th percentile) Reporting Measures: Report specific information Some percentages may apply Attest that your facility complied with requirement

Measures for CY 2015 8 Clinical Measures: 3 Reporting Measures: Adequacy (3 measures) Vascular Access (2 measures) Calcium >10.2 (3 month rolling average) BSI per 100 HD patient months (per NHSN) St. Readmission Ratio 3 Reporting Measures: Hgb level/ESA dose Phosphorus levels ICH CAHPS results –twice a year Continued 10 of the 11 measures used in PP 2014 Removed: Hgb greater than 12g/dL Added: Standardized readmission ratio (SRR) = 11 measures for PP 2015

Or Google “2017 QIP measures” Current Website to get Measure Specifications: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/Downloads/ESRDQIPPY2017finaltechnicalmeasurespecifications-.pdf Or Google “2017 QIP measures”

Clinical: Dialysis Adequacy Performance Period 2015 Performance Period 2016 Proposed for 2017 Kt/V>1.2: Adult HD (monthly) Kt/V>1.7: Adult PD (each 4 mo) Kt/V>1.2: Pediatric HD (monthly) Adding: Kt/V Dialysis Adequacy: Pediatric PD >1.8 (each 6 mo) PD counts both residual and dialytic clearance ONE measure: % of patient months where aver deliv dose of HD or PD met the specified threshold HD (all ages) Kt/V > 1.2 (2-4 X week) PD (< 18 yrs) Kt/V > 1.8 (residual & dialytic, q 6 mo) PD (> 18 yrs) Kt/V > 1.7 (residual & dialytic, q 4 mo)

Clinical: Vascular Access Type Performance Period 2015 Performance Period 2016 Proposed for 2017 AV Fistula (more is better) Central venous catheter use >90 days (less is better) No change

Clinical: Hypercalcemia Performance Period 2015 Performance Period 2016 Proposed for 2017 Proportion of adult patients (HD & PD) with a 3-month rolling average of total uncorrected serum calcium > 10.2 (lower number is better) No change

Clinical: NHSN—Blood Stream Infection Performance Period 2015 Performance Period 2016 Proposed for 2017 # of ICHD patients with positive blood cultures* per 100 HD months Data submitted within 3 months of end of each quarter No credit for < 12 months data No Improvement score; A threshold and performance standard TBD during PP No change Data from CY 2014 will be used as the comparison period for both achievement and improvement scoring; the performance standard, achievement threshold, and benchmark will be published as data for 2014 are available With the exception of the NHSN Bloodstream Infection clinical measure, we proposed to set the performance standards, achievement thresholds, and benchmarks for the PY 2017 clinical measures at the 50th, 15th, and 90th percentile, respectively, of national performance in CY 2013, because this would give us enough time to calculate and assign numerical values to the proposed performance standards for the PY 2017 program prior to the beginning of the performance period. We continue to believe that these standards will provide an incentive for facilities to continuously improve their performance, while not reducing incentives to facilities that score at or above the national performance rate for the clinical measures. As stated in the CY 2014 ESRD PPS Final Rule (78 FR 72213 through 72215), CY 2014 is the first year for which we will have data for the NHSN Bloodstream Infection clinical measure. Accordingly, we proposed to set the performance standard, achievement threshold, and benchmark for the NHSN Bloodstream Infection clinical measure based on the 50th, 15th, and 90th percentiles, respectively, of national performance in CY 2014. * Drawn as an outpatient or within 1 calendar day post hospital admit

Clinical: Standardized Hospital Readmission Rate (SRR) Performance Period 2015 Performance Period 2016 Proposed for 2017 Risk adjusted SRR (ratio of observed unplanned readmissions to the number on expected unplanned readmissions) Readmits within 30 days of discharge (DC) Facilities with <11 applicable hospital discharges are not eligible for this measure No change Index admission: Any eligible admission to an acute care hospital assessed in the measure for the outcome (readmitted or not within 30 days) An index admission is the admission with a principal diagnosis of a specified condition that meets the inclusion and exclusion criteria for the measure.

Reporting: Mineral Bone Disease Performance Period 2015 Performance Period 2016 Proposed for 2017 Report phosphorus levels monthly for in-center and home HD/PD patients No change Scoring formula: ( X 12) Number of Months Facility Successfully Reports Number of Months in the Performance Period Facility Has CCN - 2

Reporting: Anemia Management Performance Period 2015 Performance Period 2016 Proposed for 2017 Report Hgb levels and ESA doses monthly Include in-center HD patients and home patients (HD & PD) No change Scoring formula: ( X 12) Number of Months Facility Successfully Reports Number of Months in the Performance Period Facility Has CCN - 2

ICH CAHPS-Reporting Measure Must use a CMS-approved vendor Performance Period 2015 Performance Period 2016 Proposed for 2017 ICH CAHPS-Reporting Measure Must use a CMS-approved vendor Conduct survey by CMS specifications Two surveys required Spring deadline: 8/5/2016 Fall deadline: 1/27/2016 30 completed surveys submitted for facility to participate in measure (if not, attestation in CW required) ICH CAHPS-Clinical Measure Ditto 2015 plus: Composite score: The proportion of respondents answering each of response options for each of the items summed across the items within a composite to yield the composite measure score: Nephrologists’ communication and caring Quality of dialysis center care & operations Providing information to patients ICH CAHPS Clinical No change

Summary: Payment Year 2017 Measures Clinical Measures = 75% of the Total Performance Score (TPS) Vascular Access Type (2 measures) Dialysis Adequacy (3 measures) Hypercalcemia NHSN Bloodstream Infection Standardized Readmission Ratio Reporting Measures = 25% of the TPS ICH CAHPS Mineral Metabolism Anemia Management

To Avoid a Payment Penalty: PY 2017: Must Score 60 or Above Total Performance Score Reduction 100-60 0% 59-50 0.5% 49-40 1.0% 39-30 1.5% 29-0 2.0%

What’s New for PP 2016?

Clinical: Standardized Transfusion Ratio (STrR) PP 2015 Performance Period 2016 Proposed for 2017 Not included Ratio of the number of observed eligible red blood cell transfusions occurring in patients dialyzing at a facility to the number of eligible transfusions that would be expected from a predictive model that accounts for patient characteristics within each facility List of exclusions has been identified No change

Reporting: Pain Assessment and Follow Up PP 2015 Performance Period 2016 Proposed for 2017 Not included Reporting in CROWNWeb one of these six conditions for each qualifying patient; once before August 1, 2016 and once before Feb 1, 2017: 1-Pain assessment* positive and f/u plan documented 2-Pain assessment* positive; no f/u; but patient not eligible 3-Pain assessment* positive, no f/u and no reason given 4-Pain assessment* negative; no f/u required 5-No pain assessment; patient is not eligible 6-No pain assessment; no reason given No change from 2016 Score may be based on 1 report *Using a Standardized tool

Reporting: Clinical Depression Screening & F/U PP 2015 Performance Period 2016 Proposed for 2017 Not included Report in CROWNWeb one of the six conditions below for each qualifying patient once before Feb 1, 2017 1-Screening is positive; f/u plan is documented 2-Screening is positive; f/u plan not documented, patient is not eligible 3-Screening is positive; no f/u plan; no reason given 4-Screening is negative; no f/u plan required 5-Screening is not documented; but patient is not eligible 6-Screening is not documented; no reason given No change from 2016 Each facility should select the tool most appropriate for each of their patients – potential tools were identified Attest a screening was performed for each eligible patient who is 12 years or older

Reporting: NHSN Healthcare Personnel Influenza Vaccine PP 2015 Performance Period 2016 Proposed for 2017 Not included Facility submits report to NHSN by May 15, 2016 Report includes: % of employees, licensed independent practitioners, or adult/students/trainees/volunteers Who work in a dialysis facility at least one day between October 1, 2015 and March 31, 2016 Who receive a flu vaccination, were determined to have a medical contraindication, declined a vaccination or were of unknown vaccination status. No change from 2016 except update of the dates of the performance period

Summary: PY 2018 Measures Clinical Measures = 90% of TPS Reporting Measures = 10% of TPS Safety Subdomain: 20% NHSN Bloodstream Infection Patient & Family Engagement/Care Coordination Subdomain: 30% ICH CAHPS 20% SRR 10% Clinical Care Subdomain: 50% STrR 7% Dialysis Adequacy 18% Vascular Access type 18% Hypercalcemia 7% Weighted equally: Mineral Metabolism Anemia Management Pain Assessment and Follow-Up Clinical Depression Screening and Follow-Up NHSN Healthcare Personnel Influenza Vaccination

To Avoid a Payment Penalty: PY 2018: Proposed Rule: Score 39 or above Total Performance Score Reduction 100-39 0% 38-29 0.5% 28-19 1.0% 18-9 1.5% 8-0 2.0%

Proposed NEW QIP Measures for PP 2017 But Wait, There’s More! Proposed NEW QIP Measures for PP 2017

Proposed Reporting Measure: Ultrafiltration PP 2015 PP 2016 Proposed for 2017 Not included Number of months a facility reports ultrafiltration rates for each qualifying patient Exclusions include: Less than 18 yrs of age Missing a pre-dialysis weight in the reporting month (RM) Missing a post-dialysis weight in the RM Missing delivered dialysis time per session in the RM Patients with a UF value <0ml/kg/hr, or >50ml/kg/hr Includes all patients (not just Medicare) Scoring formula: Number of Months Facility Successfully Reports Number of Months in the Performance Period Facility Has CCN ( ) X 12 - 2

Proposed Reporting Measure: Full-Season Influenza Vaccination PP 2015 PP 2016 Proposed for 2017 Not included Percentage of qualifying patients for whom the facility successfully reports influenza vaccination information in CW: If the patient received a flu vaccination: Documented at facility Documented outside facility Patient self-reported outside facility If the patient did not receive a flu vaccination, reason: Already vaccinated this season Allergic or adverse reaction Other medical reason Declined Other reason Performance Period: Oct 1-Mar 31 Scoring formula: same as previously illustrated

Deadline for Comments: August 25, 2016 Note: There are errors/mistakes in the proposed rule: CMS is being asked to clarify/correct these CMS is proposing to create a manual for measure specifications, including technical information on the indicators CMS plans to do a study to determine the impact on access to care of adopting the SRR and STrR measures Study methodology will be published and comments accepted

Strategies To Improve Patient Care, Maximize Reimbursement, Improve QIP Scores, And Get Ready For 2016

“You can’t use knowledge you don’t have” Knowledge Is Key “You can’t use knowledge you don’t have” New Clinical Measures: Standardized Transfusion Ratio ICH CAHPS New Reporting Measures: Personnel Influenza Vaccination Pain Depression (not yours…)

Clinical Measure: Standardized Transfusion Ratio (STrR) Get Ready! Review anemia management to lessen risks for transfusion Educate hospitalists to reduce unnecessary transfusions Monitor transfusion rates: Build relationships with hospitals to get more complete and timely information Medicare Hospital Conditions of Participation require transfer of discharge information prior to the next treatment Educate staff to ask patients about blood transfusions post-hospitalization

Clinical Measure: ICH CAHPS Get Ready! Focus on the specific needs of each individual patient Implement strategies to make patient centered care “real” Put patient priorities first in the plan of care Recognize our part in bridging gaps in health literacy Promote shared decision-making Use proven techniques to engage patients Motivational interviewing “Teach back”

Reporting Measure: Personnel Flu Vaccination Get Ready! Performance period for this measure starts October 1, 2015 Educate all personnel (everyone with potential patient contact (e.g., physicians, volunteers, NP/PA) to this requirement NY State requires HCP who refuse vaccine to wear masks all flu season… Establish a record-keeping system Don’t forget to include personnel starting after 10/1/2015

Reporting Measure: Pain Assessment and Follow Up Get Ready! Educate staff members to this requirement Select a standardized tool Establish a record keeping system Set dates for the two required assessments in CY 2016; reschedule any patients absent on the set dates Report data from first assessment data in CROWNWeb by Aug 1, 2016 and second assessment data by Feb 1, 2017

Reporting Measure: Clinical Depression Screening & Follow Up Get Ready! Educate staff members to this requirement Select a standardized tool Establish a record keeping system Set dates for the required assessment in 2016; reschedule any patients absent on the set dates Report data in CROWNWeb by Feb 1, 2017

Knowledge Is Key Stay current with the QIP measures Be sure ALL team members (RNs, PCTs, MSWs, RDs, and physicians) are aware of QIP and the implications for payment Remember you must meet the performance standard to avoid payment reduction: aim for much higher!

gpayneful@aol.com www.nephrologyclinicalsolutions.com Questions? gpayneful@aol.com www.nephrologyclinicalsolutions.com