1. 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

2. 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
Identify actions to prepare for the 2016 performance period

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

4. 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

5. 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

6. 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

7. Frequently Cited Deficiencies: 2014
Standard Surveys 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%

8. Frequently Cited Deficiencies: 2014
Standard Surveys 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%

9. Frequently Cited Deficiencies: 2014
COMPLAINT Surveys 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%

10. Frequently Cited Deficiencies: 2014
COMPLAINT Surveys 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%

11. 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)

12. 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

13. Recent Change to Surveyor Guidance
June 12, 2015 Survey & Certification Letter 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.

14. Questions So Far?

15. What’s Up with the QIP Measures?

16. 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

17. 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

18. 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

19. Or Google “2017 QIP measures”
Current Website to get Measure Specifications:
Or Google “2017 QIP measures”

20. 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)

21. 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

22. 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 > (lower number is better)
No change

23. 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 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

24. 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.

25. 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

26. 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

27. 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

28. 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

29. 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%

30. What’s New for PP 2016?

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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%

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

38. 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

39. 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

40. 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

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

42. “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…)

43. 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

44. 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”

45. 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

46. 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

47. 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

48. 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!

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