Dialysis Facility Quality Awards Outline
Purpose: To provide an overall rating system to dialysis facilities using more than one data source and giving greater weight to the sources that provide a higher level of care and safety for the patient.
Plan: Give weighted rank to four different national sources of dialysis data and combine them for an overall composite rating of the provider. The four sources being used are the Quality Incentive Program (QIP), National Healthcare Safety Network (NHSN), the Dialysis Facility Report (DFR) and the Crown Web reporting system.
Definitions:
QIP- The Centers for Medicare & Medicaid Services (CMS) administers the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) to promote high-quality services in outpatient dialysis facilities treating patients with ESRD
The End Stage Renal Disease (ESRD) Quality Initiative promotes ongoing CMS strategies to improve the quality of care provided to ESRD patients. This initiative supports quality improvement efforts among facilities and makes available quality information that will enable patients to participate in making health care decisions.
NHSN- CDC’s National Healthcare Safety Network is the nation’s most widely used healthcare-associated infection tracking system. NHSN provides facilities, states, regions, and the nation with data needed to identify problem areas, measure progress of prevention efforts, and ultimately eliminate healthcare-associated infections.
In addition, NHSN allows healthcare facilities to track blood safety errors and important healthcare process measures such as healthcare personnel influenza vaccine status and infection control adherence rates.
DFR- TheDialysis Facility Reports(DFR) have been produced annually since 1995 under contract to the Centers for Medicare & Medicaid Services. An individual DFR is provided to each dialysis facility in the U.S. in the interest of stimulating quality improvement efforts and facilitating the quality improvement process. The DFRs allow comparisons of the characteristics of a particular facility’s patients, patterns of treatment, and patterns in transplantation, hospitalization, and mortality to local and national averages.
CROWNWeb- CROWNWeb is a Web-based data-collection system that enables Medicare-certified dialysis facilities to securely submit administrative and clinical data to the Centers for Medicare & Medicaid Services (CMS) in real time.
Rating levels:
Data Source
/Weight of Rating
QIP / 50%NHSN (BSI, ARBSI) / 20%
DFR (SMR, SHR)
/ 20%Crown Web Data Entry
/ 10%Calculation Methodology: Data from all four sources is aggregated and totaled resulting in a maximum of 100 points. Each point is equivalent to one percent for a maximum of one hundred percent. The top ten percent of facilities with the highest score will receive a “Quality Award” designating their achievement in these fields.
QIP score is calculated by taking facilities published 2015 QIP score and dividing by two resulting in a maximum score of 50 points.
NHSN data for blood stream infections (BSI’S) and access related blood stream infections (ARBSI’s) are each worth 10 points for a maximum total score of 20. The facilities will receive 10 points for each category for being in the top ten percent; 9 points given for the facilities in the 80.0-89.99 percentiles and so on until reaching the bottom ten percent, who will receive 1 point.
From the DFRthe clinic Standardized Mortality Ratios (SMR) and Standardized Hospitalization Ratio will be extracted, with the clinic receiving 10 points for a “significantly less than 1.0” rating, 5 points for a “not significantly less than 1.0” rating and 1 point for a “significantly more than 1.0” rating for each category, for a maximum total score of 20.
For those facilities that have entered 95% of their clinical Crown Web data by the close of the March reporting deadline shall receive a maximum score of 10 points. Those facilities that entered 90.0-94.99% shall receive 5 points. Facilities below 90% Crown Web entry will receive 1 point.
Conclusion: Once calculated “Quality Award” facilities receive notification and a certificate explaining their award and the measures they were scored on. These results will be published on Renal Network website to recognize the provider’s achievement, and serve as additional encouragement for facilitiesnot currently receiving the award.