What’s Up With That?

Update: CMS Surveys and the QIP Measures

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Glenda M. Payne, RN, MS, CNNDirector 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

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CMS: Core Survey Process

• All ESRD surveys are done using the Core Survey Process• Focus:

– Patient safety and– Facility responsibility for

continuous quality improvement

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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

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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

CMS Core Survey Field Manual

Preliminary Citation PatternsV Tag % Change: Core Vs. Trad. CommentV113-Hand hygiene 35% On IC ✔listsV122-Disinfect stat. 15% On IC ✔listV141-CVC care 83% On IC ✔listsV143-Aseptic meds 61% On IC ✔listV550-AVF 24% On IC ✔listV628-QAPI actions 184% On QAPI review toolV543-Fluid management 31% Focus Core surveyV544-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

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# 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

protocols581 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

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# 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

disinfected257 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

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# 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 protocols39 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

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# 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 21 2.6%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) 1 V113- IC (same)2 V122-IC (Clean equipment/surfaces) 2 V122-IC (same)3 V543-POC (Manage volume status) 3 V715- (# 6 in Standard survey)4 V403-PE (Equipment maintenance) 4 V726-Medical records: (Not in top 10 for

Standard)5 V147-IC (Catheter care) 5 V111-IC (Not in top 10 for Standard)6 V715-MD Resp (All adhere to P&P) 6 V543-POC (#3 in Standard survey)7 V143-IC (Aseptic technique for IV

meds)7 V750- CONDITION-Governance (not in top

10 for Standard)8 V116-IC (Items taken to station =

D/D/D)8 V452- Patient Rights—Respect & Dignity

(not in top 10 for Standard)9 V115-IC (Wear PPE) 9 V401-PE- (Not in top 10 for Standard)

10 V407-PE (HD patients in view [access uncovered])

10 V407-PE (same)

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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

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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.

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Questions So Far?

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What’s Up with the QIP Measures?

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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

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Two Kinds of Measures

Clinical 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

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Measures for CY 2015

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8 Clinical 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 Ratio3 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

Current Website to get Measure Specifications:

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/ESRDQIP/Downloads/ESRDQIPPY2017finaltechnicalmeasurespecif

ications-.pdf

Or Google “2017 QIP measures”

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Clinical: Dialysis AdequacyPerformance 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)

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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 • No change

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Clinical: HypercalcemiaPerformance 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 • No change

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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

• No change

23* 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 •No change

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Reporting: Mineral Bone DiseasePerformance Period 2015 Performance Period 2016 Proposed for 2017

• Report phosphorus levels monthly for in-center and home HD/PD patients

• No change • No change

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Number of Months Facility Successfully ReportsNumber of Months in the Performance Period Facility Has CCN( X 12) - 2

Scoring formula:

Reporting: Anemia ManagementPerformance 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 • No change

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Number of Months Facility Successfully ReportsNumber of Months in the Performance Period Facility Has CCN( X 12) - 2

Scoring formula:

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

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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

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To Avoid a Payment Penalty: PY 2017:

Must Score 60 or AboveTotal Performance Score Reduction

100-60 0%

59-50 0.5%

49-40 1.0%

39-30 1.5%

29-0 2.0%

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What’s New for PP 2016?

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Clinical: Standardized Transfusion Ratio (STrR)

PP 2015 Performance Period 2016 Proposed for 2017

•Notincluded

• 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

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Reporting: Pain Assessment and Follow UpPP 2015 Performance Period 2016 Proposed for 2017

Notincluded

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 documented2-Pain assessment* positive; no f/u; but patient not eligible3-Pain assessment* positive, no f/u and no reason given4-Pain assessment* negative; no f/u required5-No pain assessment; patient is not eligible6-No pain assessment; no reason given

• No change from 2016

*Using a Standardized tool

Score

may

be

base

d on

1 re

port

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Reporting: Clinical Depression Screening & F/U

PP 2015 Performance Period 2016 Proposed for 2017Not included

Report in CROWNWeb one of the six conditions below for each qualifying patient once before Feb 1, 20171-Screening is positive; f/u plan is documented2-Screening is positive; f/u plan not documented, patient is not eligible3-Screening is positive; no f/u plan; no reason given4-Screening is negative; no f/u plan required5-Screening is not documented; but patient is not eligible6-Screening is not documented; no reason given

No change from 2016

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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

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Summary: PY 2018 Measures

• 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%

Reporting Measures = 10% of TPS

Weighted equally:• Mineral Metabolism• Anemia Management• Pain Assessment and Follow-Up• Clinical Depression Screening and

Follow-Up• NHSN Healthcare Personnel Influenza

Vaccination

Clinical Measures = 90% of TPS

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To Avoid a Payment Penalty: PY 2018:

Proposed Rule: Score 39 or aboveTotal Performance Score Reduction

100-39 0%

38-29 0.5%

28-19 1.0%

18-9 1.5%

8-0 2.0%

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But Wait, There’s More!

Proposed NEW QIP Measures for PP 2017

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Proposed Reporting Measure: UltrafiltrationPP 2015 PP 2016 Proposed for 2017Not included

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)

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Number of Months Facility Successfully Reports

Number of Months in the Performance Period Facility Has CCN( X 12) - 2

Scoring formula:

Proposed Reporting Measure: Full-Season Influenza Vaccination

PP 2015 PP 2016 Proposed for 2017Not included

Not included

Percentage of qualifying patients for whom the facility successfully reports influenza vaccination information in CW:1. If the patient received a flu vaccination:

a) Documented at facilityb) Documented outside facilityc) Patient self-reported outside facility

2. If the patient did not receive a flu vaccination, reason:a) Already vaccinated this seasonb) Allergic or adverse reactionc) Other medical reasond) Declinede) Other reason

39Scoring formula: same as previously illustrated

Performance Period:

Oct 1-Mar 31

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

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Strategies To Improve Patient Care, Maximize Reimbursement,

Improve QIP Scores, And Get Ready For 2016

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Knowledge Is Key

New Clinical Measures:• Standardized Transfusion

Ratio• ICH CAHPS

New Reporting Measures: • Personnel Influenza

Vaccination• Pain • Depression (not yours…)

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“You can’t use knowledge you don’t have”

Clinical Measure: Standardized Transfusion Ratio (STrR)

• 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

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Get Ready!

Clinical Measure: ICH CAHPS

• 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”

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Get Ready!

Reporting Measure: Personnel Flu Vaccination

• 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

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Get Ready!

Reporting Measure: Pain Assessment and Follow Up

• 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

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Get Ready!

Reporting Measure: Clinical Depression Screening & Follow Up

• 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

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Get Ready!

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!

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Questions?

gpayneful@aol.com www.nephrologyclinicalsolutions.com

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