End Stage Renal Disease Network
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SECTION C. STATEMENT OF WORK
C.1. PURPOSE OF STATEMENT OF WORK (SOW)
The purpose of this Statement of Work (SOW) is to delineate tasks to be conducted by each End
Stage Renal Disease Network Organization (ESRD Network) contractor in support of achieving national quality improvement goals and statutory requirements as set forth in Section 1881 of the
Social Security Act and the Omnibus Budget Reconciliation Act of 1986. The term “Network” is used in this SOW to refer to the ESRD Network contractor. The tasks described in this SOW are intended to align Network activities with the Department of Health and Human Services (HHS)
National Quality Strategy (NQS), the CMS Three Aims, and other CMS priorities designed to result in improvements in the care of individuals with ESRD.
Background information on the ESRD Network Program can be found in the Medicare ESRD
Network Organizations Manual (ESRD Network Manual).
C.2. CONTRACT PERFORMANCE OBJECTIVES
This section outlines the objectives, priorities, and strategies of the ESRD Network Program and the role of the Network in carrying out activities as reflected in this SOW.
C.2.1. Domains
The Network shall promote positive change relative to three AIMs outlined in the NQS and CMS priorities. The AIMs are interpreted for purposes of this SOW as:
AIM 1: Better Care for the Individual through Beneficiary and Family Centered Care
AIM 2: Better Health for the ESRD Population
AIM 3: Reduce Costs of ESRD Care by Improving Care.
The three AIMS are subdivided into multiple domains, as defined in this SOW. (See Table 1.)
Many factors influence these domains, including patient characteristics, patients’ social support/environment, and aspects of the health care delivery system. To substantively impact these domains, the Network may need to deploy interventions that target patients, dialysis/transplant providers, other providers, and other stakeholders.
The Network shall incorporate a focus on disparities in conducting all of the activities outlined in this SOW. In each domain, the Network shall analyze data and implement interventions aimed at reducing disparities.
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Table 1. AIMS, Domains, and Sub-Domains
AIM
AIM 1: Better
Care for the
Individual through
Beneficiary and
Family Centered
Care
AIM 2: Better
Health for the
ESRD
Population
Domain
Patient and Family
Engagement
Patient Experience of Care
Patient-Appropriate
Access to In-Center
Dialysis Care
Vascular Access
Management
Patient Safety:
Healthcare-Acquired
Infections (HAIs)
Population Health
Innovation Pilot
Project
Sub-Domain
Foster Patient and Family Engagement at the Facility
Level
Involve Patients/Families in CMS Meetings
Convene Patient Engagement Learning and Action
Network (LAN)
Evaluate and Resolve Grievances
Promote Use of In-Center Hemodialysis Consumer
Assessment of Healthcare Providers and Systems
(ICH CAHPS) and/or Any Similar Survey Identified by CMS
Address Issues Identified through Data Analysis
Decrease Involuntary Discharges (IVDs) and
Involuntary Transfers (IVTs)
Address Patients at Risk for IVD/IVT and Failure to
Place
Generate Monthly Access to Dialysis Care Reports
Improve Arteriovenous (AV) Fistula Rates for
Prevalent Patients
Reduce Catheter Rates for Prevalent Patients
Support Facility Vascular Access Reporting
Spread Best Practices
Provide Technical Support in the Area of Vascular
Access
Recommend Sanctions
Support National Healthcare Safety Network (NHSN)
Establish HAI LAN
Reduce Rates of Dialysis Facility Events
Reduce Identified Disparity through :
Project A: Increase Hepatitis B (HBV), Influenza, and
Pneumococcal Vaccination Rates or
Project B: Improve Dialysis Care Coordination with a
Focus on Reducing Hospital Utilization or
Project C: Improve Transplant Coordination or
Project D: Promote Appropriate Home Dialysis in
Qualified Beneficiaries or
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AIM 3: Reduce
Costs of ESRD
Care by
Improving Care
Support for ESRD
Quality Incentive
Program (QIP) and
Performance
Improvement on
QIP Measures
Support for Facility
Data Submission to
CROWNWeb,
NHSN, and/or Other
CMS-Designated
Data Collection
System(s)
Project E: Support Improvement in Quality of Life
Assist Facilities in Understanding and Complying with QIP Processes and Requirements
Assist Facilities in Improving their Performance on
QIP Measures
Assist CMS in Monitoring the Quality of and Access to Dialysis Care
Assist Beneficiaries and Caregivers in Understanding the QIP
C.2.2. Role of Network
The Networks are critical to achieving bold CMS goals for health care transformation. The successful Networks will be patient care navigators and lead transformation by:
Serving as conveners, organizers, motivators, and change agents
Leveraging technology to provide outreach and education
Serving as partners in quality improvement with beneficiaries, practitioners, health care providers, other health care organizations, and other stakeholders
Securing commitments to create collaborative relationships
Achieving and measuring changes at the patient level through data collection, analysis, and monitoring for improvement
Disseminating and spreading best practices including those relating to clinical care, quality improvement techniques, and data collection through information exchange
Participating in the development of a CMS national framework for providing emergency preparedness services.
The Network is uniquely positioned to ensure full participation of the ESRD community in achieving the AIMS of the NQS. Therefore, this SOW emphasizes:
Network relationship with Medicare beneficiaries
Ensuring representation of Medicare beneficiaries in shared decision making related to ESRD care in order to promote person-centeredness and family engagement (NQS Principle 1)
Protecting Medicare beneficiaries’ access to and quality of dialysis care, especially among vulnerable populations (NQS Principle 3).
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Network relationship with ESRD facilities ( NQS Principle 4 )
Identifying opportunities for quality improvement at the individual facility level and providing technical assistance ( NQS Principle 5 )
Promoting all modalities of care, including home modalities and transplantation, as appropriate, to promote patient independence and improve clinical outcomes ( NQS Principle 5 )
Facilitating processes to promote care coordination between different care settings ( NQS Principle 8 )
Ensuring accurate, complete, consistent, and timely data collection, analysis, and reporting by facilities in accordance with national standards and the ESRD QIP ( NQS Principle 6 ).
Coordination and sharing across 18 Networks
Using standardized procedures to collect data and address grievances to promote consistency across Networks ( NQS Principle 6 )
Collaborating to share information such as patient migration across
Networks to promote care coordination ( NQS Principle 8 )
Coordinating with regional Quality Improvement Organizations (QIOs) and other recognized subject matter experts in the quality improvement field
Sharing information to promote care coordination for ESRD patients
( NQS Principle 8 )
Sharing best practices to improve quality of care for ESRD patients, including Network involvement in LANs ( NQS Principle 5 ).
Network acting on behalf of CMS
Conveying information from CMS to facilities on HHS and CMS goals, strategies, policies, and procedures including the ESRD QIP
Maintaining integrity of information and tone of messaging consistent with CMS expectations for entities acting on behalf of the agency
Interpreting and conveying to CMS or its designee information relevant to the ESRD health care system to assist with monitoring and evaluation of policy and program impacts including the effects of the ESRD QIP.
C.3. GENERAL REQUIREMENTS
C.3.1. Internal Quality Control (IQC) Program
The objectives of the IQC Program are to support and foster continuous quality improvement in
Network processes in order to improve the timeliness, effectiveness, efficiency, and management control of Network activities.
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The Network shall develop a written IQC Plan that encompasses the work to be performed under this contract including administrative functions, financial management, and activities in support of the three AIMs.
The Network shall have an internal reporting system for all IQC activities, and shall make reports available to its Medical Review Board (MRB) and, on request, to CMS.
The Network IQC Program shall include built-in processes for rapid identification and correction of problems.
The Network IQC Plan shall be submitted to the Contracting Officer’s Representative (COR) for review no later than 45 days after the beginning of the contract year, unless otherwise directed by
CMS. Upon request by the COR, the Network shall supply IQC reports and analyses to document adherence to established processes and response to problems that arise in performing contract requirements.
C.3.2. Compliance
The Network shall comply with all requirements outlined in this SOW, all additional instructions from CMS, and all relevant statutory and regulatory requirements.
C.3.3. Independence
The Network, acting independently and not as an agent of the Federal Government, shall furnish the necessary personnel, materials, services, facilities, and supplies (except as otherwise specified in the contract) and otherwise do all things necessary for, or incident to, the performance of work as set forth by this SOW.
C.3.4. Corporate Structure
The Network shall establish a corporate structure that supports the Network’s operations and meets all statutory requirements. The corporate structure shall include a Network Council, Board of
Directors, Medical Review Board, and Patient Advisory Committee at a minimum. Network key personnel (Executive Director, Quality Improvement Director, Patient Services Director, and Data
Manager) are required. The Network shall maintain on file all CMS-furnished ESRD Network
Nondisclosure Statements signed by all Network employees and affiliates. All aspects of the corporate structure must meet ESRD Network Manual requirements. (See the ESRD Network
Manual for additional information.)
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C.3.5. Communication Requirements
The Network shall work with patients and providers in its service area to improve the quality of care and quality of life of ESRD patients by providing informational material and technical assistance on ESRD-related issues. All Network correspondence to patients and to providers for distribution to patients shall be clear, concise, well-organized, and easily understood on the first reading by readers who are literate in English, regardless of functional or health literacy status and professional or academic background. Materials shall be appropriately translated for non-English speakers, as applicable. In addition, all Network correspondence to patients and facilities for distribution to patients shall contain the following language: “ To file a grievance please contact
[insert Network name] at [insert Network phone number, e-mail address, mailing address, and website URL]
.”
The Network shall perform the following functions:
Maintain a national user-friendly, toll-free telephone number: The Network’s toll-free number shall be answered by a staff person during normal working hours. After hours, the system shall allow messages to be left. Systems shall be in place to ensure that a
Network staff member can be reached by telephone in the event of an emergency or disaster.
Maintain a Network website: The Network website must be Section 508 compliant and follow all CMS standards and guidelines. The Network website shall include, at a minimum, a description of the Network grievance process; a list of the Network’s goals; the Network’s most recent Annual Report; a link to the Dialysis Facility
Compare website (http:www.medicare.gov/dialysis); information on all Network committees, including information on how to become a member of each committee; a link to the ESRD QIP site and other specified federal websites as directed by CMS; and in the event of an emergency or disaster, the open and closed case status of providers and other information to assist patients and providers.
Prepare a cover letter for the New ESRD Patient Orientation Package (NEPOP):
Using Network stationary, the Network shall make a letter available for duplication and distribution to new ESRD patients in the Network’s service area. The letter shall be provided to the National Coordinating Center (NCC) to distribute in the NEPOP, with a copy to the Network's COR when the content is revised or as otherwise directed by CMS. The letter shall:
Explain the role of Network
Give the Network’s toll free number, mailing address, and website address
Provide the address(es) and phone number(s) for the State Survey
Agency(ies) in the Network’s service area
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Provide information on the functions of State Survey Agencies, including the role of the State Survey Agency in receiving and investigating grievances
Include information on how to contact the Network in order to file a grievance (phone number, e-mail address, and mailing address).
Investigate and resolve situations in which NEPOPs are undeliverable: Using an IQC process, the Network shall track the error rate for distribution of the packet on initial mailing and set an acceptable target for the error rate. The Network shall report on these activities quarterly.
Provide educational information: The Network shall determine the most effective strategies for the distribution of informational materials, utilizing the basic principles of marketing and consumer engagement. The process for distributing informational material shall be based on a thorough knowledge of the specific needs of the ESRD patient population in the Network’s service area. The Network shall use an IQC process to determine the need for educational/informational materials for its community, to determine the most effective method of distribution for each type of material, and to evaluate the overall effectiveness of the materials and the method of distribution. To the extent possible and practical, the Network shall utilize information that is already available through CMS, other CMS contractors (e.g., other Networks, the NCC, QIOs), other federal agencies, renal partners (e.g., renal advocacy groups, provider groups, and provider associations), and other sources. As applicable, the
Network shall utilize the Patient Advisory Committee and Network Council in fulfilling these requirements. Educational/outreach materials must include information on:
The role of the ESRD Network
The Network's process for receiving, reporting, resolving, and tracking patient grievances
Treatment options and new ESRD technologies available to patients, with an emphasis on those that have been shown to support patient independence (e.g., transplantation, home therapies, in-center self-care)
Information to educate and encourage patients to achieve their maximum level of rehabilitation and to participate in activities that will improve their quality of life (e.g., vocational rehabilitation programs, volunteerism); contact information for state/regional vocational rehabilitation programs available in the Network’s service area
Information on vascular access procedures
The Network’s toll-free number, mailing address, and website address
Information on how to access and use the Dialysis Facility Compare website
Information on how to interpret a facility’s QIP Performance Score
Certificate
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Information on all Network committees, including information on how to become a member of each committee
Information on the importance of receiving vaccinations (including
HBV, influenza, and pneumococcal vaccinations) and information related to the importance of disease management, the Welcome to
Medicare Physical, heart-healthy living, diabetes self-management and training, and (if requested) smoking cessation
Information on the benefits of the Medicare Prescription Drug Program
(Medicare Part D) and on how to enroll, and any other guidance or materials related to this program of specific benefit to the individual with ESRD, as directed by CMS.
C.3.6. Data Confidentiality and Disclosure
Pursuant to §1881(c)(8) of the Social Security Act, the Network must comply with the QIO data confidentiality requirements found in §1160 of the Act and 42 CFR, Part 480.
C.3.7. Information Collection/Survey Activities
Unless otherwise specified, a Network seeking to conduct surveys or collect data as a part of any of the activities included in this SOW shall do so only with pre-approval of the COR and in accordance with the Paperwork Reduction Act, the ESRD Network Manual, and other administrative directives.
C.3.8. Network Reporting
As applicable, the Network shall maintain meeting minutes required for the tasks identified in the
SOW and the Schedule of Deliverables. The Network shall report to CMS as directed in the SOW and in the Schedule of Deliverables. As specified in this contract and approved by CMS, the
Network may conduct data analysis and produce data reports relevant to the local provider community and/or CMS. The Network shall maintain a repository of all data acquired and reports generated. No new data collection may be implemented by the Network without CMS approval.
The Network shall report to CMS as directed in Section F – Schedule of Deliverables. The
Network shall adhere to all requirements in the ESRD Network Manual to manage and report work performed under this SOW.
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The Network shall submit the following reports to the COR and Government Task Leader (GTL) for approval:
Monthly Reports
Quarterly Progress and Status Reports
Semi-Annual Cost Report
Annual Report of Network Activities
Other deliverables as directed by this SOW and the Schedule of Deliverables.
C.3.9. Meetings
The Network shall host, participate in, and attend meetings as directed in Section F – Schedule of
Deliverables. ESRD Network meetings shall include:
Contract post-award Meeting with CMS
Monthly Meetings with the COR/GTL: The Network shall prepare an agenda and meeting minutes for each meeting. The meeting shall address each AIM—progress in meeting the Deliverable schedule and other contract requirements—and shall include a review of the Network IQC Plan. The IQC Plan and progress updates shall be provided to the COR/GTL electronically to allow for a WebEx-based meeting in which the COR is able to see the Network’s progress if requested by the COR.
The annual QualityNet conference or another CMS quality meeting(s) designated by
CMS as requiring in-person Network participation. The Networks are expected to participate in QualityNet meetings as presenters and/or conveners of learning sessions as directed by CMS.
National meetings related to Network task areas requiring Network attendance and participation as directed by CMS
Other national meetings as specified in this SOW or as directed by CMS
At least one QIO community-based LAN: The Network shall participate in the QIO
LAN to advocate for better coordinated care and improved quality of care for ESRD patients in the QIO’s state/jurisdiction. If the Network covers more than one state/jurisdiction, the Network shall actively engage with at least one of the QIO LANs in the Network’s service area.
Meetings related to the ESRD QIP as directed by CMS.
C.3.10. Collaboration with Network Coordinating Center
The Network Coordinating Center ( NCC) will function as a knowledge repository of Network- generated information (including best practices and lessons learned) and perform aggregate data analysis and interpretation of data from the Networks.
The Network shall:
Assist with the NCC’s knowledge repository and data analysis function by submitting data generated from its activities to the NCC as specified by CMS
Focus its activities based on trends detected or analyses performed by the NCC as
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directed by CMS
Participate in the collection and dissemination of best practices and other forms of knowledge transfer.
C.3.11. Collaboration with State Survey Agency
The Network shall engage the State Survey Agency as a partner in achieving common goals to improve access to and quality of care for dialysis patients. Regular two-way communication shall be maintained.
The Network shall communicate with the State Survey Agency and CMS (ESRD Network Program staff and Survey and Certification staff) on a formal basis at a minimum of every other month and share issues and/or findings related to quality, access and coordination of care. The Network must promptly contact the State Survey Agency and coordinate management of a response plan when the issue reported may result in harm to the patient.
The State Survey Agency shall be invited to participate as a member of the Network Patient
Engagement LAN.
C.3.12. Sanctions
The Network shall recommend sanctions pursuant to §1881(c)(2) of the Social Security Act and procedures outlined in the ESRD Network Manual. The Network shall conduct a thorough review of a facility reporting more than 2 IVD/IVTs per month or 3 IVD/IVTs per quarter, to ensure regulatory/statutory compliance and consider exercising its authority to recommend sanctions against recalcitrant facilities. Network interventions shall primarily focus on beneficiaries and their families/caregivers as well as facility process improvements. The Network shall consider recommending sanctions for facilities that:
Endanger the lives of patients being treated for ESRD, and/or engage in inappropriate practice patterns
Demonstrate a pattern of not accepting the Network’s offers of technical assistance
Demonstrate a pattern of non-adherence to Network recommendations
Do not meet Network-determined benchmarks as required by CMS
Do not meet CMS and Network goals relative to clinical performance measures and ESRD QIP measures
Do not demonstrate evidence of effective quality improvement activities that result in continuous quality improvement for those clinical areas in which the facility is not meeting benchmarked national standards.
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C.3.13. Reporting of Discrimination
If it is suspected that care is being compromised or denied due to discrimination on the basis of race, color, religion, national origin, age, sex, familial status, sexual orientation, gender identity, disability, or veteran status, the case should be referred to the Office for Civil Rights (OCR) for investigation. The CMS COR, GTL, and Contracting Officer must also be notified.
C.3.14. Emergency Preparedness
The Network shall provide an Emergency Preparedness Plan to CMS and cooperate with the NCC in coordinating emergency preparedness activities for the renal community. The Network shall provide technical assistance to dialysis facilities when needed so that facilities develop feasible, comprehensive emergency plans. The Network shall comply with the emergency preparedness duties outlined in the ESRD Network Manual.
The Network shall participate in an annual emergency preparedness drill in conjunction with the
NCC. The Network shall coordinate the date and activity with the appropriate local stakeholders
(state disaster agencies, State Survey Agencies, CMS Regional Office Division of Survey &
Certification, etc.) and the NCC utilizing data to support the selection of the focus of the drill that is deemed most important to the Network’s service area (e.g., earthquake, tornado, terrorist activity). At the completion of the drill, the Network shall perform and document the results of an assessment of strengths, weaknesses, opportunities for improvement, and lessons learned. Copies of the assessment will be sent to the NCC, GTL, and COR within 30 calendar days of the completion of the drill.
C.3.15. Data Systems
The Network shall not develop software products for use by facilities or other Networks without written prior approval from CMS. In addition, no funds from this contract shall be used for data collection activities not specified in this contract without prior approval from the COR and in accordance with other CMS administrative guidance.
C.3.16. Infrastructure Operations Support and Data Management
Unless otherwise directed by CMS, the Network shall adhere to the most current version of the policies and procedures outlined and posted on the QualityNet and NCC websites. These include, but are not limited to, the ESRD Network Infrastructure Operations and Support Manual, the
ESRD Network Information Technology (IT) Administrator Manual, the SDPS Database Systems
Administrator Guide, the QualityNet System Security Policy, and the QualityNet Incident
Response Procedures. The Network shall comply with all present and future statutes as well as federal, Department of Health and Human Services (DHHS), and CMS regulations and program
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The Network shall maintain all necessary documentation that meets or exceeds the performance standards specified in the Infrastructure Operations Support and Data Management chapter of the
ESRD Network Manual and deliverables specified in Section F – Schedule of Deliverables.
C.3.17. Hardware/Software
CMS, either directly or through a CMS contractor, shall provide each Network with a file/print server, a domain controller, a database server, and a workstation and/or laptop for each 0.5 or greater full-time-equivalent (FTE) employee. The servers, workstations, and laptops shall be equipped with a standard operating system and a software suite following approved CMS Federal
Desktop Core Configuration (FDCC) standards. If the Network requires additional hardware and/or software, the Network must receive approval from the Engineering Review Board (ERB). The
Network must pay for the additional equipment and software out of Network contract funds. No additional hardware peripherals or non-approved software may be connected or installed to any
Government Furnished Equipment (GFE) without prior written approval by CMS.
C.3.18. Security
C.3.18.A. Certification by Information System Security Officer (ISSO) for
Compliance with CMS Systems Security Requirements
The Network ISSO or equivalent, also referred to as the Security Point of Contact (SPOC), shall assist the CMS QualityNet ISSO in the security certification of existing controls and compliance with the CMS systems security requirements as described in the CMS Acceptable Risk Safeguards
(ARS) and the Federal Information Security Management Act (FISMA), Title III of the E-
Government Act of 2002 (Public Law 107-347, 44 U.S.C. Ch 36).
C.3.18.B. Administer Security Program
The Network shall comply with all CMS security program requirements as specified in the CMS
Information Security (IS) “Virtual Handbook” (a collection of CMS policies, procedures, standards, and guidelines that implements the CMS Information Security Program) and the
QualityNet Security Policy. The Virtual Handbook can be found at http://www.cms.hhs.gov/informationsecurity and the QualityNet Security Policy is located at http://qualitynet.org/ .
The Network shall comply with all security controls outlined in the CMS Information Security (IS)
Acceptable Risk Safeguards (ARS) for “Moderate” systems. Appropriate references are the CMS
IS ARS, Appendix B, and the CMS System Security Levels by Information Type (located at http://www.cms.hhs.gov/informationSecurity in the Info Security Library).
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The Network shall comply with the CMS Policy for the Information Security Program (PISP) and all CMS methodologies, policies, standards, and procedures contained in the CMS PISP unless otherwise directed by CMS in writing.
The Network shall comply with CMS and OIG audits, reviews, evaluations, tests, and assessments of Network systems, processes, and facilities. The Network shall provide all related artifacts upon request. The Network shall deliver the artifacts using the format and method prescribed by CMS.
The Network shall visit the CMS security website ( http://sww.cms.hhs.gov/informationsecurity ) at least every 30 calendar days for updates.
The Network shall visit the QualityNet Conference website ( http://www.qualitynetonline.com/ ) with appropriate frequency for QualityNet Program and Security briefings and training opportunities.
The Network shall participate in CMS Security Best Practices conferences and audio conferences as directed by CMS.
The Network shall document its compliance with CMS security requirements and maintain such documentation in the Network System Security Plan (SSP) and the Information Security (IS) Risk
Assessment (RA) as directed by CMS.
C.3.18.C. Correct Deficiencies
The Network shall correct any security deficiencies, conditions, weaknesses, findings, or gaps identified by all audits, reviews, evaluations, tests, and assessments, including but not limited to
Office of Inspector General (OIG) audits, self-assessments, Network internal review, Network security audits, and vulnerability assessments in a timely manner.
C.3.18.D. Security Review and Verification
The Network shall comply with the CMS Security Assessment and Authorization (SA&A) methodology, policies, standards, procedures, and guidelines for contractor facilities and systems
( http://www.cms.hhs.gov/InformationSecurity/14_standards.asp
).
The Network shall conduct or undergo, as specifically selected and directed by CMS, an independent evaluation and test of its systems security program in accordance with CMS Reporting
Standard for Information Security testing and adhere to the prescribed template
( http://www.cms.hhs.gov/InformationSecurity/14_standards.asp
) The Network shall support CMS validation and accreditation of contractor systems and facilities in accordance with CMS’ SA&A methodology.
The Network shall provide annual certification in accordance with SA&A methodology that certifies it has examined the management, operational, and technical controls for its systems supporting the Network contract function and considers these controls adequate to meet CMS’ security standards and requirements.
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C.4. AIMS AND DOMAINS
C.4.1. AIM 1: Better Care for the Individual through Beneficiary and Family
Centered Care
CMS strives to promote health care that is respectful of and responsive to individual patient preferences, needs, and values. Network patient-centered domains to achieve AIM 1 are:
Patient and Family Engagement
Patient Experience of Care
Patient-Appropriate Access to In-Center Dialysis Care
Vascular Access Management
Patient Safety: Healthcare-Acquired Infections (HAIs).
In CMS’ view, most Network activities will be enhanced by the patient’s voice. The Network shall take a two-tiered approach to incorporating the patient’s voice in the activities of the Network and the renal community as a whole. The two tiers are: (1) engagement at the dialysis facility level to foster patient and family involvement; (2) development and implementation of a beneficiary and family centered care focused LAN to promote patient and family involvement at the Network level.
Both tiers are essential and work together to promote beneficiary and family engagement to improve quality of care.
In addition, the Network shall collaborate with the appropriate State Survey Agency(ies) to support patient and family engagement.
Patient Subject Matter Experts (Patient SMEs) are committed and informed patients who are representative of the demographic characteristics of the Network’s service area, and who participate in the Network-convened Patient Engagement LAN. These patients will provide a patient perspective for Network improvement activities. The Network shall:
Provide at least 20% of facilities located in the Network area with Patient SME agreement forms to identify patients to participate in Patient and Family Engagement activities within 30 days of contract award
Recruit at least 10 Patient SMEs for within 60 days of contract award, three of whom must be eligible patients on the transplant waitlist
Submit a list of Patient SMEs who have signed agreement forms to CMS. (See the
ESRD Network Manual.)
Document the active participation of Patient SMEs and their contributions in the
Monthly Reports. Provide an update on the number of participants who remain active in Patient and Family Engagement activities including the Patient LAN throughout the course of the contract. Active involvement can be demonstrated by multiple means including lists of attendance at meetings, webcasts, conference calls; documented requests for technical assistance; documented requests for resources; or an attestation of participation signed by the participant.
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C.4.1.A. Patient and Family Engagement
C.4.1.A.1. Foster Patient and Family Engagement at the Facility Level
The Network shall assist providers in adjusting to the heightened focus on patient and family centered care, aiming to help them optimize customer service. Specifically, the Network shall:
Develop and submit to the COR within 30 days of the start of the contract a marketing plan that integrates the concepts of family engagement and patient-centered care. (See the
ESRD Network Manual.)
Fully implement the marketing plan within 120 days of contract award
As part of any onsite visits to dialysis facilities, incorporate discussion, education, and evaluation of how the dialysis facility has implemented patient and family centered care.
For example:
Review and discuss with the facility whether the Quality Assurance
Performance Improvement Program includes patient and family participation
Review for the presence of patient and family meetings (e.g., patient council, support groups, vocational rehabilitation groups, new patient adjustment groups)
Review and discuss patient and family involvement in the governing body of the facility
Review and discuss policy and procedures related to family participation in the patient’s care such as involvement in the development of the individualized plan of care and cannulation
Determine the percentage of patients and/or family members/caregivers who participate in plan of care meetings
By the 4 th
Quarter of the base contract year, synthesize information on dialysis facilities’ patient and family engagement in the Network service area to determine needs and future social marketing efforts for Option
Years 1 and 2.
C.4.1.A.2 Involve Patients/Families in CMS Meetings
The Network shall incorporate patients/family members into CMS meetings as follows and record attendance in the meeting minutes:
Attendance by at least one Patient SME, family member, and/or caregiver in one
CORmonthly monitoring meeting per quarter. In one COR/Network monthly meeting per quarter, the Network will dedicate an agenda item(s) to patient-related topic(s) and provide the attending Patient SME(s) with a 10 minute opportunity to address the agenda topic, raise additional for discussion and/or provide an agenda item for the next quarter meeting.
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Attendance by at least one Patient SME, family member, and/or caregiver at the Network’s annual evaluation site visit. During the Network’s annual evaluation site visit, the Network and its COR will dedicate at least an hour of time to provide the attending Patient SME(s) with an overview of Network operations, an overview of CMS oversight and an opportunity for the Network and/or COR to answer Patient SME questions.
Participation in other CMS meetings as directed. See the ESRD Network Manual for additional guidance.
C.4.1.A.3. Convene/Support Patient LAN
LANs are mechanisms by which large-scale improvement around a given aim is achieved through the use of various change methodologies, tools, and/or time-bounded initiatives. LANs manage knowledge as a valuable resource. They engage leaders around an action-based agenda. LANs create opportunities for in-depth learning and problem solving. While all dialysis facilities and other ESRD providers in a given state or ESRD Network service area may not receive direct ESRD
Network interventions, LANs create an opportunity for communities, with assistance and guidance from the ESRD Network, to harness the knowledge, skills, and abilities of community partners to reach a critical mass of the appropriate stakeholders in the community concerned with a common aim(s).
The Network shall develop and facilitate a sustainable Patient Engagement LAN in the Network area to promote patient and family engagement. The LAN shall be patient-driven with topics chosen by the Patient Subject Matter Experts (Patient SMEs) participating in the LAN. Patient
SMEs are committed and informed patients who are representative of the demographic characteristics of the Network’s service area, and who participate in the Network-convened Patient
Engagement LAN. These patients will provide a patient perspective for Network improvement activities.
As directed by CMS and as resources allow, the Network shall also participate in any CMSsupported and/or facilitated LANs that function to support ESRD Network activities at the local level through spreading knowledge gained from counterparts across the country such as any applicable QIO LANs, dialysis facilities and other ESRD providers, large dialysis organizations
(LDOs), the National Institutes of Health National Kidney Disease Education Program
(NIH/NKDEP), the Centers for Disease Control and Prevention (CDC), the United States Renal
Data System (USRDS), and the University of Michigan Kidney Epidemiology and Cost Center
(UMKECC).
CMS staff will participate in the Patient Engagement LAN on a consistent basis.
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The Network shall:
Develop and submit to CMS within 30 days of the start of the contract a Patient
Learning and Action Network Plan. The Plan shall include, at a minimum, the
Patient SME participation list; additional stakeholders included in the LAN (e.g., family members/caregivers, practitioners, providers, patient advocacy groups, local/state/federal government representatives, and other renal community members); the intended roles of the LAN participants; frequency of meetings; proposed patient-driven area(s) of focus; and the intended result of LAN activities with target milestones. (See the ESRD Network Manual.)
Document the active participation of Patient SMEs and their contributions to LAN activities in the Monthly Reports.
Provide an update on the number of participants who remain active in the LAN throughout the course of the initiative. Active involvement can be demonstrated by multiple means including lists of attendance at meetings, webcasts, conference calls; documented requests for technical assistance; documented requests for resources; or an attestation of participation signed by the participant.
At the regional level, the input from Patient SMEs and their family members and/or caregivers will be used by the LAN to help guide Network activities. The Network shall use technology such as conference calls or webinars to conduct meetings; schedule meetings when patients can likely attend; and help patients understand how they can best contribute and add value to the meetings.
During the base contract year, the Network shall establish the LAN with 10 or more patients. The
Network shall maintain 100% membership with 60% attending required meetings and activities throughout the course of the project.
The Network shall ensure that at least four LAN meetings are held with patient participation during the base contract year, documenting the goals and accomplishments of the meetings. A copy of the minutes of these meeting shall be provided to the COR and GTL electronically within 15 days of each meeting.
The Patient Engagement LAN, including the 10 Patient SMEs as well as providers and other stakeholders, shall accomplish the following for each contract year:
Identify ways to spread best practices and design and implement a Quality
Improvement Activity (QIA) that promotes patient-centered care and protects the interest of beneficiaries, such as a QIA that focuses on empowering patients to share in decision-making, enhancing quality of life, and exploring treatment modalities including home dialysis. The Network shall submit a QIA Plan for COR approval by the end of the 2 nd Quarter for the base contract year, and by the end of the 1 st Quarter for Option Years 1 and 2. The QIA Plan must incorporate sound methodology as provided by the ESRD Network Manual, and shall identify a single primary process or outcome measure for evaluation purposes. The QIA methodology shall impact at least
10% of the Network population, and the Network shall demonstrate at least a 5% relative improvement on the pre-specified primary measure by the end of the 4 th
Quarter of the contract year. Additional measures can be employed at the Network’s
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and Patient SMEs’ discretion. Monthly results from the QIA shall be provided to CMS electronically as directed by CMS.
Ensure implementation of at least two campaigns developed by the LAN by the end of the 2 nd Quarter of the base contract year, and two additional campaigns by the end of the 1 st Quarter of Option Years 1 and 2. Campaigns must include development of educational materials intended for beneficiaries such as materials focused on health literacy, effectively navigating the dialysis system, treatment modalities, disease management, heart healthy living, ways to optimize quality of life, patient safety, promoting vaccinations, reducing disparities, increasing appropriate transplant referrals, reducing IVDs, or other patient-centered goals. The campaigns must be approved by the COR, and must incorporate sound methodology. For each campaign, the Network shall identify a single primary process or outcome measure for evaluation purposes. The campaign methodology shall impact at least 20% of the Network-area population, and the Network shall demonstrate at least a 10% relative improvement on the pre-specified primary measure for each campaign. Additional measures can be employed at the Network’s and Patient SMEs’ discretion. Monthly results from each campaign shall be provided to CMS electronically as directed by CMS.
The Network shall report monthly on the activities conducted by the LAN in the Monthly Report.
The LAN component of the report shall include information that addresses the following questions:
What activities were completed during the reporting period? What new learning was generated, and how was the learning shared with other stakeholders in the Network’s service area?
In addition, the Network shall enlist 3 of the 10 participating Patient SMEs and/or their families/caregivers to serve as representatives on the NCC Patient LAN by the end of the 1 st
Quarter of the base contract year. Participating Patient SMEs and their families will interact by teleconference or webcast with the NCC at least quarterly. At the national level, the input from participating Patient SMEs will be used in the development of national materials designed to improve care.
As requested by CMS, the Network shall enlist any 3 of the 10 Patient SMEs and/or their families/caregivers to provide feedback for the ESRD QIP and any ESRD QIP materials.
C.4.1.A.4. Contract Monitoring and Evaluation: C.4.1.A Patient and Family Engagement
CMS will monitor the Network on a quarterly basis using the minimum performance criteria specified in the following table.
Table 2: Minimum Performance Criteria for C.4.1.A. Patient and Family Engagement
Measure
Patient and family engagement in CMS
At least one
Patient SME, family member,
Quarter 1
At least one
COR monthly call attended by a Patient
Minimum Performance Criteria
Quarter 2
At least one
COR monthly call attended by a Patient
Quarter 3
At least one
COR monthly call attended by a
Quarter 4
At least one
COR monthly call attended by a Patient
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Patient and family engagement in CMS meetings
Patient
Engagement
LAN – commitments secured and participant engagement
Patient
Engagement
LAN –
Network activities and outputs and/or caregiver attends at least one
COR monthly monitoring meeting per quarter
At least one
Patient SME, family member, and/or caregiver attends at least one day of the CMS evaluation site visit
Maintain100
% membership with 60% attending required meeting and activities throughout the course of the project; recruit to replace lost members as applicable
Implement a
QIA developed by the LAN that promotes patientcentered care and protects the interest of
SME, family member, and/or caregiver
N/A
Maintain
100% membership with 60% attending required meeting and activities throughout the course of the project
SME, family member, and/or caregiver
N/A
Maintain
100% membership with 60% attending required meeting and activities throughout the course of the project
Develop QIA Project must be started by the end of 2nd
Quarter.
If project started in the
1st Quarter, evidence of improvement over baseline
Patient SME, family member, and/or caregiver
SME, family member, and/or caregiver
At least one
Patient SME, family member, and/or caregiver attends at least one day of the CMS evaluation site visit
Maintain
100% membership with 60% attending required meeting and activities throughout the course of the project
N/A
Maintain
100% membership with 60% attending required meeting and activities throughout the course of the project
Any improvement over the previous quarter
>5% relative improvement over the course of the project during the contract period
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Patient
Engagement
LAN –
Outreach
Campaigns beneficiaries
QIA(s) shall be COR- approved, and shall identify a single primary process or outcome measure for evaluation purposes
Implement at least two campaigns developed by the LAN that impact at least 20% of the Network population per campaign
Develop campaigns and establish goals
C.4.1.B. Patient Experience of Care must be demonstrated by end of 2 nd
Quarter
Both campaigns shall be started by the end of the 2nd
Quarter; report any evidence toward goal achievement
Demonstrate d progress toward goal(s), or goal(s) achieved
>10% relative improvement per campaign
C.4.1.B.1. Evaluate and Resolve Grievances
The Network’s case review responsibilities shall include the review of grievances and Quality of
Care Reviews.
The sources of grievances are beneficiaries and family members/caregivers. The sources for
Quality of Care Reviews include beneficiaries and individuals other than beneficiaries, e.g., State
Surveyors, family members/caregivers, and CMS staff. The Network shall utilize a number of tools intended to address the identified concerns, including implementation of QIAs and, for grievances, surveying of beneficiary/family member/caregiver satisfaction with the grievance process and outcome.
Network responsibilities under C.4.1.B.shall focus on conducting activities to meet, in an efficient and effective manner, regulatory and statutory requirements and to foster Network quality improvement efforts relative to the grievance process. To this end, the Network shall work with the
NCC to conduct patient satisfaction surveys relative to satisfaction with the grievance process.
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The Network shall also work collaboratively with the appropriate State Survey Agency(ies) to maximize the linkage between case review information obtained during investigation of a grievance and the survey process. The information obtained from the grievance process, satisfaction survey data, and the collaboration with the State Survey Agency will foster quality improvement at the state and local levels.
Evaluation and resolution of grievances includes a structured investigation of processes of a dialysis facility/transplant center, and may include medical record review, review of policies and procedures, and review of staffing plans. (See the ESRD Network Manual.)
The Network shall:
Inform patients of the Network’s role in receiving, reporting, resolving, and tracking patient grievances in accordance with the communications requirements in C.3.5.
Adhere to the definition of grievances and the grievance resolution process described in the ESRD Network Manual
Enter data on grievances into the Network Contact Utility (NCU) tool or other
CMS-designated database. The Network shall document patient grievances directly reported to the Network by patients and/or grievances reported to facilities by patients.
Perform grievance review and assist in the resolution of grievances
Document the patient’s perceptions of the reason for filing the grievance
Document what steps were taken by the facility and Network to resolve each grievance and whether the resolution was satisfactory to the patient
Include a summary of grievance review activities and findings in the Monthly
Report. The Network shall provide detailed findings and statistics related to any specific facility with a trend identified. The Network shall adhere to established timeframes set forth in Section F – Schedule of Deliverables.
Perform Quality of Care Reviews (peer reviews): The Network through its MRB shall, as appropriate, evaluate the quality of care delivered to beneficiaries based on medical record review, interviews with facility physicians and other staff, review of policy and procedures, etc.
Maintain review timeliness for all cases at or greater than 90%
Networks will ensure that 100% of all beneficiary data for filed grievances be submitted to the NCC.At the end of the 1 st and 3 rd Quarters, conduct a focused audit of all grievances received to identify systemic issues and trends. Potential quality of care concerns found during the audit shall be documented in the CMSdesignated system as part of the grievance review process.
Adhere to the required investigatory and documentation elements in 100% of grievance cases. (See the ESRD Network Manual for the required investigatory documentation elements.)Investigate whether any grievance is potentially related to the ESRD QIP or PPS incentives or may be indicative of disparities in care
Using 1 st Quarter findings, identify one grievance trend to address by implementing a QIA with at least 5 facilities with the highest numbers of grievances in that trend area. The Network shall develop a QIA Plan and submit it for COR approval within 120 days from the start of the contract period. The QIA
Plan shall reflect sound methodology, and shall identify a single primary process
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CMS-2012-ESRD-FFPRENEWAL or outcome measure for evaluation purposes. The Network shall follow up to ensure that the actions specified in the plan have been taken and were successful.
The Network shall demonstrate at least a 1 percentage point improvement in the identified facilities from baseline to the end of the base contract year. (At CMS’ direction, the QIA shall be expanded to include at least 20% of the facilities in the
Network’s service area, and the Network shall demonstrate a minimum 10% relative improvement on the pre-specified measure.) Furthermore, upon completion of the project, the Network shall determine if the QIA can be applied system-wide. This determination is based on whether the intervention activities deployed can have an impact beyond the individual beneficiaries and providers involved in the QIA, can result in tangible improvement to a system or process, and will improve the quality of health care for Medicare beneficiaries in the
Network’s service area. The QIA results shall be reported to CMS in the Monthly
Report.
Promptly contact the State Survey Agency and coordinate management of a
response plan when the issue reported may result in imminent harm to the patient
Work with, and implement activities to support, the CMS Ombudsman as directed by CMS, and provide aggregated data for the Ombudsman Report.
C.4.1.B.2. Contract Monitoring and Evaluation: C.4.1.B.1. Evaluate and Resolve Grievances
CMS will monitor the Network on a quarterly basis using the minimum performance criteria specified in the following table.
Table 3: Minimum Performance Criteria for C.4.1.B.1. Evaluate and Resolve Grievances
Measure Minimum Performance Criteria
Timeliness of review
Beneficiary grievances per quarter
Beneficiary satisfaction with the grievance process
Timeliness of review
Beneficiary grievances per quarter
Satisfaction
Survey results
Quarter 1
Timeliness of review for
>90% of cases
Network reviews >6 beneficiary grievances per quarter
N/A
Quarter 2
Timeliness of review for
>90% of cases
Network reviews >6 beneficiary grievances per quarter
N/A
Quarter 3
Timeliness of review for
>90% of cases
Network reviews >6 beneficiary grievances per quarter
N/A
Quarter 4
Timeliness of review for
>90% of cases
Network reviews >6 beneficiary grievances per quarter
At least 80% of respondents to Satisfaction
Survey indicate they are satisfied or very satisfied by end of evaluation
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Quality
Improvement
Activity
(QIA)
Grievance management
Develop a
QIA with at least 5 facilities based on data entered into NCU
100% of grievance cases adhere to the required investigator y and documentat ion elements according to the
ESRD
Network
Manual
Baseline quarter
100% of grievance cases were investigated and appropriately documented in the NCU tool or other CMSdesignated system
Demonstrate progress toward at least
1 percentage point improvement, or at CMS direction toward 10% improvement
100% of grievance cases were investigated and appropriately documented in the NCU tool or other
CMSdesignated system
Demonstrate progress toward at least
1 percentage point improvement, or at CMS direction toward 10% improvement
100% of grievance cases were investigated and appropriately documented in the NCU tool or other
CMSdesignated system period**
Achieve at least 1 percentage point improvement, or 10% improvement if required by
CMS
Based on a
CMS comprehensiv e review,
100% of grievance cases were investigated and documented appropriately*
**
*When the denominator is an odd number, the denominator will be rolled down to the next whole number.
**This includes cases available from January 1, 2013, through the end of the base contract year evaluation period. Thereafter the measure is based on data from the end of the previous evaluation period to the end of the current evaluation period.
***The comprehensive review criteria differ from the quarterly review criteria. See the ESRD
Manual.
C.4.1.B.3. Promote Use of ICH CAHPs and/or Any Similar Survey Identified by CMS
The Network shall encourage outpatient hemodialysis facilities to utilize the ICH CAHPS tool following the AHRQ guidelines posted at http://www.cahps.ahrq.gov
and to report ICH CAHPS information as directed by CMS . The Network shall inform providers of ESRD QIP Patient
Experience of Care Survey usage measure requirements and encourage provider activities to successfully fulfill the measurement requirements starting within 90 days of the effective date of
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CMS-2012-ESRD-FFPRENEWAL this contract. Any requirements in this section also apply to any other similar survey identified by
CMS, including quality of life surveys, for any modality.
During the base year of this contract, the Network shall track the number of facilities that are utilizing the ICH CAHPS tool and provide that information to CMS in an electronic format, as directed. At the direction of CMS, during Option Year 1 and/or Option Year 2, the Network shall develop a QIA based on the results from the ICH CAHPS. Patient involvement and approval must be demonstrated in the QIA provided to the COR for approval.
The COR-approved QIA shall incorporate sound methodology as provided by the ESRD Network
Manual, and shall identify a single primary process or outcome measure for evaluation purposes.
The QIA methodology shall impact at least 10% of the Network population and a minimum of 20 dialysis facilities, and the Network shall demonstrate at least a 5% relative improvement on the pre-specified primary measure. Additional measures can be employed at the Network’s and patients’ discretion. Monthly results from the QIA shall be provided to CMS electronically as directed by CMS.
C.4.1.B.4. Address Issues Identified through Data Analysis
The Network shall track provider participation in administering the ICH CAHPS. As ICH CAHPS data become available, the Network shall assist facilities with interpretation of results and development of action plans to improve patients’ experience of care. The Network shall assist facilities with conducting trend analyses to evaluate for disparities in care. These data will assist facilities in capturing improvement over time.
C.4.1.C. Patient-Appropriate Access to In-Center Dialysis Care
CMS strives to assure appropriate access to in-center dialysis care for ESRD patients who require life-sustaining dialysis treatment and who are not candidates for home modalities. It is the responsibility of the Network to work with individual facilities to identify and address issues related to difficulties in placing patients in dialysis facilities, and in identifying patients at risk for
IVD/IVT or failure to place.
C.4.1.C.1. Decrease IVDs and IVTs
The Network shall:
Process data submitted by facilities on IVDs/IVTs and enter the data into the NCU tool or other CMS-designated system within 5 days of notification by the facility of an IVD/IVT
Use the appropriate terms and definitions/criteria for documenting IVDs/IVTs per the ESRD Network Manual
Investigate any IVD/IVT and document the investigation in the NCU tool or other
CMS-designated system
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Respond to patient and/or facility report of IVDs/IVTs within 5 business days to begin resolution efforts. See the ESRD Network Manual for detailed tasks/procedures.
Document characteristics of patients that may be indicative of disparities in care, including race, ethnicity, new ESRD versus established patient, as defined in the
ESRD Network Manual, including those that may be related to the ESRD QIP or the PPS.
The Network shall work with and encourage facilities to avert IVDs/IVTs whenever possible to ensure the Network goal of providing patient and family centered care.
C.4.1.C.2. Address Patients at Risk for IVD/IVT and Failure to Place
The Network shall:
Based on interactions with patients and/or facilities, investigate and document any patients perceived by the Network to be at risk for IVD/IVT and/or failure to place as a new patient in the NCU database, or other CMS-designated system, within 24 hours of receiving the information.,
Document characteristics of patients, including race, ethnicity, incident versus prevalent patient, as defined in the ESRD Network Manual, including those that may be related to the ESRD QIP or the PPS,
Work with dialysis facilities to facilitate the placement of patients, including the option of home dialysis if appropriate, with the goal of ensuring that all patients in the Network’s service area have access to dialysis care in the appropriate care setting, including the option of home dialysis if appropriate. The Network shall contact CMS to discuss exclusions as defined in the ESRD Network Manual.
C.4.1.C.3. Contract Monitoring and Evaluation: C.4.1.C.1. Decrease IVDs and IVTs and
C.4.1.C.2. Address Patients at Risk for IVD/IVT and Failure to Place
CMS will monitor the Network on a quarterly basis using the minimum performance criteria specified in the following table.
Table 4: Minimum Performance Criteria for C.4.1.C.1. Decrease IVDs and IVTs and
C.4.1.C.2. Address Patients at Risk for IVD/IVT and Failure to Place
Measure
Reduce IVDs/IVTs Number of
IVDs/IVTs
Minimum Performance Criteria
Quarter 1 Quarter 2 Quarter 3 Quarter 4
Baseline quarter using NCU data*
At least 5% fewer or 1 less
IVD/IVT, whichever
At least 5% fewer or 1 less
IVD/IVT, whichever
At least 5% fewer or 1 less
IVD/IVT, whichever is
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Avert potential
IVDs/IVTs
Percent of potential
IVDs/IVTs averted
Baseline quarter using NCU data*
At least 5% fewer or 1 less
IVD/IVT, whichever is greater, compared with the previous
At least 5% fewer or 1 less
IVD/IVT, whichever is greater, compared with the previous
At least 5% fewer or 1 less
IVD/IVT, whichever is greater, compared with the previous quarter** quarter** quarter**
*If the Network is at 0% for any quarter, the Network shall sustain this level within 5% or 1 person, whichever is greater, for the following quarters.
**If the Network is at 100% for any quarter, the Network shall sustain this level within 5% or 1 person, whichever is greater, for the following quarters.
C.4.1.C.4. Generate Monthly Access to Dialysis Care Reports
The Network shall generate monthly reports for the Network service area that interpret and synthesize available summary statistics on beneficiaries who were involuntarily discharged or transferred or were at risk for IVD/IVT or failure to place during the contract period. The Network shall submit these reports to CMS and the appropriate State Survey Agency(ies). (See the ESRD
Network Manual.)
C.4.1.D. Vascular Access Management
AV fistula use has increased steadily from 34.1% of prevalent hemodialysis patients in December
2003 to 59.6% of prevalent patients in August 2011, with two Networks exceeding the Fistula First
Breakthrough Initiative (FFBI) target rate of 66%. Over the combined life of the FFBI, all ESRD
Networks and every state have demonstrated improvement. Despite this, the goal of at least 66%
AV fistula use has not yet been achieved nationally. Although rates of AV fistula use among prevalent patients vary across states and Networks, this variation has decreased overall over time.
Factors contributing to the remaining variations brought to light in the 2011 FFBI Report include physician vascular access choice, patient characteristics, and the degree to which patients begin chronic dialysis with a permanent access. For example, Networks with the highest rates of AV fistula use (>60%) among prevalent patients had on average higher percentages of patients who were male, Hispanic, and/or white than Networks with lower rates of AVF use. Nationally, more
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81% of incident dialysis patients began dialysis using a catheter in 2011, although the Northeastern and Northwestern regions had higher percentages of incident patients with AV fistulas.
C.4.1.D.1. Improve AV Fistula Rates for Prevalent Patients
Through this SOW, the ESRD Networks are charged with achieving and sustaining the goal of at least a 68% AV fistula-in-use rate for prevalent patients. Using the October data that are available in December of the prior calendar year as a baseline, the Network shall reduce its quality deficit by
20% by the end of the 3 rd Quarter of the base contract year unless the expected improvement is less than the floor of 1.0 percentage point or greater than the ceiling of 4.0 percentage points, in which case the floor or ceiling shall apply. Monthly goals will be established based on a linear projection toward meeting the evaluation goal. The Network shall achieve at least 75% of its monthly goal each month. Failure to comply with contract expectations is defined as failing to meet 75% of the monthly goal in any three consecutive months.
C.4.1.D.2. Reduce Catheter Rates for Prevalent Patients
The Network shall also track long-term catheter use rates (catheter in use >90 days) via the FFBI
Dashboard and shall target a Network reduction in the rate of long-term catheter use among prevalent patients by at least 2 percentage points in dialysis facilities that have a >10% rate of longterm (>90 days) catheter use in prevalent patients at baseline. Monthly goals will be established based on a linear projection toward meeting the evaluation goal. The Network shall strive to achieve at least 75% of its monthly goal each month. Failure to comply with contract expectations is defined as failing to meet 75% of the monthly goal in any three consecutive months.
C.4.1.D.3. Support Facility Vascular Access Reporting
The Network shall support 100% of applicable dialysis facilities in the submission of vascular access data, as required by CMS, using the Fistula First data collection tool or another method(s) as provided by CMS .
(See the ESRD Network Manual for a list of exclusions.) The Network shall be responsible for knowing the fistula use rates of all facilities in its service area and for reporting to the Network’s COR if there is a concern with facility reporting.
C.4.1.D.4. Spread Best Practices
Additionally, successful interventions and system changes shall be spread to the other facilities in the Network’s service area and shared with the NCC, any appropriate LAN, and other Networks.
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C.4.1.D.5. Provide Technical Support in the Area of Vascular Access
The Network shall provide, but is not limited to, the following technical support activities for dialysis facilities in the area of vascular access:
Targeted technical assistance for lower performing providers
Root cause analyses
Implementation of evidenced-based interventions: Over the years, a number of interventions have been employed and several best practices have emerged. The
Network shall propose the intervention(s) that it plans to use in achieving the AV fistula-in-use goal based on the assessment of the population served and regional considerations that may be indicative of disparities in care. The FFBI Annual
Report and the Fistula First website ( www.fistulafirst.org
) provide information that can be used by the Network as it considers the most appropriate intervention(s) for its service area. The Network shall include interventions aimed at decreasing the use of catheters in an effort to promote catheters last and fistulas first. The
Network shall evaluate the effectiveness of all implemented interventions.
C.4.1.D.6. Recommend Sanctions
The Network shall recommend sanctions as appropriate. (See C.3.12. Sanctions.)
C.4.1.D.7. Contract Monitoring and Evaluation: C.4.1.D. Vascular Access Management
CMS will monitor the Network on a quarterly basis using the minimum performance criteria specified in the following table.
Table 5: Minimum Performance Criteria for C.4.1.D. Vascular Access Management
Measure
Vascular access–
AVF monthly goals
Vascular access –
AVF 3 rd
Quarter goal
Meet at least
75% of monthly goal.
Reduce quality deficit by 20% unless the expected improvement is less than the floor of 1.0
Quarter 1
Monthly goal improvement
N/A
Minimum Performance Criteria
Quarter 2
Monthly goal improvement
N/A
Quarter 3
Monthly goal improvement
Achieve
Network goal per SOW
Quarter 4
Monthly goal improvement
Continued improvement
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Vascular access – monthly catheter goal percentage point or greater than the ceiling of 4.0 percentage points, in which case the floor or ceiling shall apply
For designated intervention facilities, the
Network meets at least 75% of monthly goal .
Monthly goal improvement
Monthly goal improvement
Monthly goal improvement
Monthly goal improvement
Vascular access – 3 rd
Quarter catheter goal
Vascular access – facility reporting
Reduce catheter in use >90 days rates by >2 percentage points for facilities that have long-term catheter use rates >10% at baseline
Submission of vascular access data from 100% of applicable facilities
N/A
Quarterly demonstrate
100% monthly reporting
N/A
Quarterly demonstrate
100% monthly reporting
Achieve goal Continued
Quarterly demonstrate
100% monthly reporting improvement
Quarterly demonstrate
100% monthly reporting
C.4.1.E. Patient Safety: HAIs
The March 1, 2011, issue of the Morbidity and Mortality Weekly Report published by the Centers for Disease Control and Prevention (CDC) noted that there were 25,000 fewer central-lineassociated bloodstream infections (CLABSIs) in U.S. intensive care units in 2009 compared with
2001, a 58% reduction ( http://www.cdc.gov/mmwr/pdf/wk/mm60e0301.pdf
). This represents up to
6,000 lives saved and $414 million in cost savings in 2009, and approximately $1.8 billion in cumulative costs savings since 2001. Unfortunately, the CDC also noted that a substantial number of CLABSIs continue to occur in outpatient hemodialysis centers, identifying an important focus area for expanded prevention efforts. CLABSI prevention in dialysis facilities will require increased adherence to current inpatient CLABSI prevention recommendations, development and
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CMS-2012-ESRD-FFPRENEWAL implementation of additional prevention strategies specific to the dialysis environment, and collection and analysis of data. Critical to hemodialysis patients are efforts to reduce central line use (as outlined in C.4.1.D. Vascular Access Management) and improved maintenance of longterm central lines for patients unable to attain another access type.
The Secretary of Health and Human Services has launched the Partnership for Patients campaign, which focuses on reducing healthcare-associated conditions including HAIs such as bloodstream infections, referred to as Dialysis Facility Events in the NHSN. The Partnership for Patients is a public-private partnership that offers support to physicians, nurses, and other clinicians working in all care settings to make patient care safer and support effective transitions of patients from hospitals to other settings. The Partnership is an important part of CMS’ work to improve the quality of care available to Medicare beneficiaries. The Networks will contribute to this goal by working to reduce rates of HAIs, referred to as Dialysis Facility Events.
C.4.1.E.1. Support NHSN
In support of the 2014 QIP requirement, the Network shall ensure that at least 90% of all facilities in the Network service area are successfully enrolled in the NHSN database within the base contract year. The Network will be measured monthly. Monthly goals will be established based on a linear projection toward meeting the evaluation goal. The Network shall achieve at least 75% of its monthly goal each month Failure to comply with contract expectations is defined as failing to meet 75% of the monthly goal in any three consecutive months.
In addition, by the end of the base contract year, 80% of facilities must be reporting Dialysis
Facility Event data for at least six consecutive months. Monthly goals will be established based on a linear projection toward meeting the evaluation goal. The Network shall strive to achieve at least
75% of its monthly goal each month. Failure to comply with contract expectations is defined as failing to meet 75% of the monthly goal in any three consecutive months.
The Network shall provide education and support to the dialysis facilities in the NHSN enrollment process. Additionally, the Network shall assist facilities in ensuring that data are entered into the
NHSN database accurately and in a timely manner.
The Network shall establish itself as the group administrator for the NHSN database system for the dialysis facilities in the Network’s service area. In addition, the Network shall obtain group administrator rights from every facility in the Network’s service area. The Network shall conduct at least one QIA per contract year to reduce Dialysis Facility Event rates by at least a 5% relative improvement in the reporting facilities. The Network shall utilize the CDC intervention materials developed to reduce infection rates as a primary intervention.
At least 80% of all facilities in the Network’s service area shall be successfully reporting at least six consecutive months of Dialysis Facility Event data to NHSN within the base contract. CMS anticipates that many facilities will work to achieve the ultimate goal of NHSN reporting for 12 months of the year in order to receive the incentives associated with the ESRD QIP. As a result,
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C.4.1.E.2. Establish HAI LAN
To develop and spread best practices, The Network shall establish and support an HAI LAN that is open to all facilities in the Network’s service area. CMS has charged the QIOs with establishing
HAI LANs that are primarily focused on the reduction of HAIs in the hospital setting. CMS is encouraging Networks to consult with the local QIO(s) to determine if there are potential areas of synergy between the LANs, related to sharing change packages, tools, experience reporting to
NHSN, and other potential commonalities. CMS working in collaboration with CDC and the NCC will provide guidance to the Network for facilities participating in the LAN.
C.4.1.E.3. Reduce Rates of Dialysis Facility Events
The Network shall work through facilities to reduce Dialysis Facility Event rates in outpatient facilities by:
Working in collaboration with CMS and CDC to increase NHSN enrollment by actively promoting awareness of, access to, and use of CDC technical assistance in enrolling facilities and reporting data
Sharing best practices in the area of reducing HAIs (Dialysis Facility Events).
At the direction of CMS, the Network shall develop and implement a COR-approved QIA based on infection data obtained from the NHSN database for each contract year. The COR-approved QIA shall be based on sound methodology as provided in the ESRD Network Manual, and shall utilize
Dialysis Facility Event reduction as its single measure for evaluation purposes. Additional, nonevaluation measures may be added at the Network’s discretion. The QIA methodology shall impact at least 20% of the Network-area facilities reporting Dialysis Facility Event data, with a minimum of 5% of the Network population included. The QIA shall demonstrate at least a 5% relative improvement on the Dialysis Facility Event primary measure. Monthly results from the QIA shall be provided to CMS electronically as directed by CMS.
C.4.1.E.4. Contract Monitoring and Evaluation: C.4.1.E. Patient Safety: HAIs
CMS will monitor the Network on a quarterly basis using the minimum performance criteria specified in the following table.
Table 6: Minimum Performance Criteria for C.4.1.E. Patient Safety: HAIs
Measure Minimum Performance Criteria
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Network assistance in NHSN database enrollment
Ensuring reporting of Dialysis
Facility
Event data
Reduce
HAIs
>90% of all facilities in the
Network service area successfully enroll in the
NHSN database
9 80 % of facilities must be reporting
Dialysis
Facility Event data for at least six consecutive months
Develop and implement a
QIA based on infection data obtained from the NHSN database that impacts at least
20% of the
Network-area facilities reporting
Dialysis
Facility Event data, with a minimum of
5% of the
Network population included.
Quarter 1
Baseline: number of providers with successful enrollment in
NHSN database
Baseline quarter: number of facilities reporting
Baseline quarter based on NSHN data
Quarter 2
Meet at least
75% of monthly goal each month,
Meet at least
75% of monthly goal.
.
Progress toward goal
Quarter 3
Meet at least
75% of monthly goal each month ,
Quarter 4
>90% of all facilities in the Network service area successfully enrolled
Meet at least
75% of monthly goal.
Progress toward goal
> 80% of facilities reporting
Dialysis
Event data for at least six consecutive months
>5% relative improvement on the
Dialysis
Facility
Event primary measure
C.4.2. AIM 2: Better Health for the ESRD Population
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The Network’s activities to promote AIM 2 shall focus on improving the quality of and access to
ESRD care through a Population Health Innovation Pilot Project in one of the following areas that are pre-approved as CMS priorities:
Increase HBV, Influenza, and Pneumococcal Vaccination Rates
Improve Dialysis Care Coordination with a Focus on Reducing Hospital Utilization
Improve Transplant Coordination
Promote Appropriate Home Dialysis in Qualified Beneficiaries
Support Improvement in Quality of Life.
Each Network shall conduct one project and shall achieve the pre-specified outcome(s) for all evaluation measures (1 to 3 measures per topic) for the topic chosen as well as demonstrate reduction in an identified disparity.
The objective of the Innovation Pilot Projects is to support achievement of national quality improvement goals and statutory requirements as set forth in Section 1881 of the Social Security
Act and the Omnibus Budget Reconciliation Act of 1986.
C.4.2.A. Population Health Innovation Pilot Projects: Technical Considerations
The Network’s Innovation Pilot Project shall adhere to the confidentiality and disclosure requirements set forth in Section 1881 of the Social Security Act, the Omnibus Budget
Reconciliation Act of 1986, and all applicable CMS administrative directives.
Any data given to the Network by the Government shall be used only for the performance of the
Innovation Pilot Projects unless the Contracting Officer specifically permits another use in writing.
If the Contracting Officer permits the Network the use of Government-supplied data for a purpose other than solely for the performance of this Innovation Pilot Project and, if such use could result in a commercially viable product, the Contracting Officer may negotiate a financial benefit to the
Government. This benefit should most often be in the form of a reduction in the price of the
Innovation Pilot Projects; however, the Contracting Officer may negotiate any other benefits he/she determines is adequate compensation for the use of the data.
Upon the request of the Contracting Officer, or the expiration of these Innovation Pilot Projects, whichever shall come first, the Network shall return or destroy all data given to the Network by the
Government. However, the Contracting Officer may direct that the data be retained by the Network for a specific period of time, which period shall be subject to the agreement of the Network. If the data are to be destroyed, the Network shall furnish direct evidence of such destruction in a form that the Contracting Officer shall determine is adequate.
The Network shall comply with all CMS guidelines regarding the appropriate de-identification of data related to both individuals and facilities, consistent with the guidelines concerning disclosure of ESRD data.
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C.4.2.B. Population Health Innovation Pilot Projects: Requirements
The Network shall work with its MRB, Network Council, Patient Advisory Committee, and, as appropriate, external stakeholders such as QIO(s), provider and practitioner associations, and beneficiary groups, to develop one Innovation Pilot Project that utilizes innovation to advance the purpose and strategic goals of the ESRD Network Program. These projects are directly aligned with areas of health care identified in the NQS and CMS goals. The Network shall identify data sources and stakeholders, and specify appropriate measurable outcomes and evaluation tools as part of the proposal phase. Data gleaned from these projects shall be used to impact quality improvement in the care delivered to ESRD beneficiaries as well as to identify trends that may be indicative of disparities in care.
The Network shall select a focus for its Population Health Innovation Pilot Project based on: (a) the opportunity for improvement and (b) an identified disparity.
As the first step in choosing a focus for its Population Health Innovation Pilot Project, the Network shall select one of the five CMS-approved project areas. The Network shall then determine, using
4 th Quarter 2012 data, whether <85% of the target population demonstrated the desired outcome(s) for the selected project area. If >85% of the target population demonstrated the desired outcome(s), the Network shall select one of the other project areas that met the <85% criterion.
The Network shall then conduct a disparity assessment for its chosen project area using data for the
4 th Quarter of 2012. Disparities shall be assessed in the following order:
Race (African American vs. White)
Ethnicity (Hispanic vs. Non-Hispanic)
Facility Location (Urban vs. Rural)
Gender (Male vs. Female)
Age (Younger than Age 65 vs. 65 and older).
The highest ordered disparity with at least 5 percentage points difference between the designated categories will be utilized for the project. For example, if for improving transplant coordination there is a 3 percentage point disparity for Race and a 10 percentage point disparity for Ethnicity, the project would focus on Ethnicity. For project areas with multiple outcomes, disparities are assessed using a simple average (mean) of findings for the various outcomes.
The Network shall inform the COR and GTL of the topic area chosen by February 15, 2013, in writing with explicit explanation of the process and data used to derived the selection. The baseline data collection and analysis for the selected project shall be completed by March 31, 2013.
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C.4.2.C. Population Health Innovation Pilot Projects: Contract Monitoring and
Evaluation
The Population Health Innovation Pilot Projects present new opportunities for the Networks to improve the quality and efficiency of services rendered to Medicare beneficiaries through learning activities associated with review and analysis of Medicare data (i.e., data from CROWNWeb,
KDQOL, and other CMS-sanctioned data collection systems), input from providers, beneficiaries, and other experts in the field, employment of proven quality improvement techniques, and identification and spread of best practices.
The bold and innovative approach to change involved in the Population Health Innovation Pilot
Projects does not lend itself well to the traditional forms of contract evaluation, which are more suited for assessing performance by the Network alone rather than engagement in collaborative partnerships to strive for maximal, sustainable improvement. Evaluation remains, nonetheless, important as such high expectations require quantitative and qualitative measures of accountability to ensure forward progress and prudent use of limited resources. Quantitative evaluation of the
Innovation Pilot projects shall be based on successfully reducing the disparity for the outcome measure(s) by at least 1 percentage point, and achieving the pre-specified thresholds for each project area. Failure in either quantitative component shall result in an unsuccessful evaluation for the project.
In addition to any approved metrics, the following attributes will serve as the basis for assessing performance:
Rapid Cycle Improvement in Quality Improvement Activities and Outputs: The
Network shall regularly reassess the value of the interventions and technical assistance used for the project. The Network shall make interim adjustments based on the feedback it receives from its participants and CMS as well as from its own performance monitoring toward achieving contractual bold goals. This will include how details on how well the Network builds a system for monitoring performance and how well it uses rapid cycle improvement to make adjustments to achieve ever higher performance and remove defects
Customer Focus and Value of the Quality Improvement Activities to Beneficiaries,
Participants, and CMS: The Network shall regularly seek to meet the needs of its customers, involving beneficiaries and other stakeholders in all aspects of quality improvement activities. Customer input should help to shape the design and ongoing operations of activities. Beneficiaries representing the diversity of the population served shall be actively engaged in activities. Solicitation of customer feedback may focus on questions such as: How relevant were the topics to the work of the participants? How well did the project meet the needs of beneficiaries, other participants, and CMS? What was the perceived quality of the activities as reported by the beneficiaries, participants, and CMS? What are suggested areas of improvement?
Ability to Prepare the Field to Sustain the Improvement : Early on in the project the
Network shall begin establishing a plan to increase the probability that the quality improvement(s) are maintained or improvement continues when the Network completes its formal work with the participants. The Network shall be expected to provide a framework and education for the project participants that will allow them to
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Value Placed on Innovation: The Network shall demonstrate solicitation and/or creation of new ideas that maximize improvement for the project participants. This includes designing a mechanism by which all entities the Network works with and/or has contact with as part of the project are able to contribute ideas that may be of value to the Network’s improvement work. It may also include the development of one or more new products, services, or features for the benefit of the project participants.
Commitment to Boundarilessness: The Network shall demonstrate the ability to identify and engage multiple entities to impact improvement for patients and/or providers. This includes but is not limited to entities outside of CMS such as state, local, and national health care organizations, patient advocacy groups, professional associations, and others.
Unconditional Teamwork: The Network shall demonstrate its ability to work with other
Networks and stakeholders to spread improvement activities that are working. The
Network is expected to demonstrate sharing of best practices with other Networks as well as project participants and partners.
The Network shall demonstrate a reduction in the identified disparity in addition to achieving the outcome(s) designated in Tables 7A–7E. The Network shall achieve a reduction in disparity by at least 1 percentage point; improvement in the value for the less-advantaged group is insufficient to warrant successful evaluation. For example, if the transplant referral rate improves from 28 percent to 33 percent for patients classified as Hispanic, while the Non-Hispanic referral rate improves from 38 percent to 47 percent, this would be insufficient to warrant receiving a successful evaluation for this project due to a failure to reduce the disparity.
In addition to meeting the general disparity reduction requirement and the specified measure(s) performance criteria associated with the project area, the Network shall demonstrate positive improvement over the course of the project. The Network shall strive to achieve at least a 0.1 percentage point increase in the value of the measure(s) each month. Failure to comply with contract expectations is defined as failing to achieve at least a 0.1 percentage point increase in any two consecutive months. This requirement does not apply to the disparity reduction. Data for the selected project shall be reported to CMS monthly as directed by CMS through this SOW or through supplemental CMS communication.
The Network shall be monitored and measured for improvement on an ongoing basis through data reported to CMS and COR review. Failure to meet all requirements of a chosen project, including but not limited to data reporting for all components of the project, specific requirements related to disparity determination, and achievement of required evaluation goals, will be referred to the
Contracting Officer for determination of appropriate contract action. The Network may not opt for a different project after the end of the first quarter of the contract period.
Throughout this Innovation Pilot Project, the Network shall provide leadership and subject matter expert guidance for the project’s quality improvement efforts in collaboration with the GTL and
COR. The Network shall submit all required reports and deliverables in accordance with Section F
– Schedule of Deliverables.
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C.4.2.D. Project A: Increase HBV, Influenza, and Pneumococcal Vaccination Rates
The Network shall identify at least 10 low-performing facilities to participate in the project. All measures must be implemented in all facilities in the target group.
The Network shall use the tool provided by CMS to establish the baseline by the end of the first quarter of the base contract year, and for all measurement throughout the project.
Facility Staff Influenza Vaccination: The Network shall achieve a 10 percentage point increase over baseline by the end of the 3 rd contract quarter or the Network evaluation, whichever is later.
Patient HBV and Pneumococcal Vaccination: The Network shall achieve a 5 percentage point increase by the end of the 3 rd contract quarter or the Network evaluation, whichever is later, for each of the two vaccine types.
Table 7A: Minimum Performance Criteria for Project A: Increase HBV, Influenza, and
Pneumococcal Vaccination Rates
Measure Measure
Definition Quarter 1
Minimum Performance Criteria
Interim Monthly
Progress
Evaluation
Staff influenza vaccination
Proportion of eligible staff who received influenza vaccination
Establish baseline
Maintain positive performance as defined by SOW
Achieve at least a
10 percentage point increase*
Achieve at least a 5 percentage point increase*
Patient hepatitis B vaccination
Patient pneumococcal vaccination
Proportion of eligible patients who received HBV vaccination
Proportion of eligible patients who received
Establish baseline
Establish baseline
Maintain positive performance as defined by SOW
Maintain positive performance as defined by SOW pneumococcal vaccination
*By end of 3 rd contract quarter or Network evaluation, whichever is later.
Achieve at least a 5 percentage point increase*
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C.4.2.E. Project B: Dialysis Care Coordination with a Focus on Reducing Hospital
Utilization
The Network shall work with a sufficient number of facilities to sustain at least 1,000 ESRD patients throughout the project (i.e., at baseline and for each month). The patient population at the target facilities shall have an aggregate standardized hospitalization ratio >25% at baseline.
Measurement will be obtained from CMS-specified Hospitalization measures in CROWNWeb, with data reported to CMS for the targeted facility population on a monthly basis.
The project shall achieve at least a 2 percentage point reduction in the hospitalization ratio by the end of the 3 rd contract quarter or the Network evaluation, whichever is later.
Table 7B: Minimum Performance Criteria for Project B: Improve Dialysis Care
Coordination with a Focus on Reducing Hospital Utilization
Measure Minimum Performance Criteria
Quarter 1 Interim Monthly Evaluation
Hospital admission rate
Number of inpatient admits/number
Progress
Establish baseline Maintain positive performance as defined by SOW of patients
*By end of 3 rd contract quarter or Network evaluation, whichever is later.
Achieve at least a
2 percentage point reduction*
C.4.2.F. Project C: Improve Transplant Coordination
The project shall include at least 10% of dialysis facilities in the Network’s service area, which shall represent at least 8% of the eligible ESRD patient population regardless of modality. The baseline transplant referral rate in the target population shall be less than 50% of eligible patients.
The project shall demonstrate at least a 5 percentage point increase in the rate of transplant referrals for eligible patients by the end of the 3rd contract quarter or the Network evaluation, whichever is later. Measurement shall be obtained from a CMS-specified Transplant Referral measure in
CROWNWeb. Data for the targeted population shall be reported to CMS on a monthly basis as directed by this SOW or through supplemental CMS communication.
Table 7C: Minimum Performance Criteria for Project C: Improve Transplant
Coordination
Measure Minimum Performance Criteria
Quarter 1 Interim Monthly
Progress
Transplant referral
Percent of eligible patients referred
Establish baseline Maintain positive performance as for transplant defined by SOW
*By end of 3 rd contract quarter or Network evaluation, whichever is later.
Evaluation
Achieve at least a 5 percentage point increase*
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C.4.2.G. Project D: Promote Appropriate Home Dialysis in Qualified Beneficiaries
The Network shall work with a sufficient number of facilities to include at least 10% of the
Network area in-center hemodialysis patient population at baseline and throughout the project. The
Network shall demonstrate at least a 7 percentage point improvement in the appropriate use of home dialysis by qualified beneficiaries by the end of the 3 rd contract quarter or the Network evaluation, whichever is later. Measurement shall be obtained from a CMS-specified Modality measure in CROWNWeb. Data for the targeted population shall be reported to CMS on a monthly basis as directed by this SOW or through supplemental CMS communication.
Table 7D. Minimum Performance Criteria for C.4.2.G. Project D: Promote Appropriate
Home Dialysis in Qualified Beneficiaries
Measure
Promote home dialysis in qualified beneficiarie
Increase percent of eligible patients receiving home hemodialysis or
Minimum Performance Criteria
Quarter 1 Interim Monthly Evaluation
Progress
Establish baseline Maintain positive performance as defined by SOW s peritoneal dialysis
*By end of 3 rd contract quarter or Network evaluation, whichever is later.
Achieve at least a
7 percentage point increase*
C.4.2.H. Project E: Support Improvement in Quality of Life
The Network shall include a sufficient number of dialysis facilities to comprise a patient population that represents at least 10% of the Network in-center hemodialysis population. The Network shall use the CMS-mandated KDQOL measures for this project. The Network has the option for this topic of demonstrating improvement on the overall KDQOL score by at least 10 percentage points,
OR improving the score for each of the renal-specific subcomponents by at least 6 percentage points. Improvement for either option shall be achieved by the end of the 3 rd contract quarter or the
Network evaluation, whichever is later. Moreover, whether using the overall KDQOL score or the three subcomponent measures, the Network shall utilize only the CMS-sanctioned KDQOL assessment tool. The Network shall provide monthly data updates for this project to CMS as specified by future communication.
Table 7E. Minimum Performance Criteria for C.4.2.H. Project E: Support Improvement in
Quality of Life
Measure Minimum Performance Criteria
Quarter 1 Interim Monthly
Progress
Evaluation
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Overall quality of life
KDQOL items
1–36
Establish baseline Maintain positive performance as defined by SOW
Achieve at least
10 percentage point improvement*
*By end of 3 rd contract quarter or Network evaluation, whichever is later.
OR
Measure
Ability to accomplish desired tasks
Depression and anxiety
KDQOL items
13–16
KDQOL items
17–28
Minimum Performance Criteria
Quarter 1 Interim Monthly Evaluation
Progress
Establish baseline Maintain positive
Establish baseline performance as defined by SOW
Maintain positive performance as
Achieve at least 6 percentage point improvement*
Achieve at least 6 percentage point improvement*
How much kidney disease interferes with
KDQOL items
29–36
Establish baseline defined by SOW
Maintain positive performance as defined by SOW daily life
*By end of 3 rd contract quarter or Network evaluation, whichever is later.
Achieve at least 6 percentage point improvement*
C.4.3. AIM 3: Reduce Costs of ESRD Care by Improving Care
The ESRD QIP continues a long tradition of work by CMS to improve the quality of care for beneficiaries with ESRD. Since 1978, Medicare has worked through the ESRD Networks to monitor and improve the quality of care furnished to ESRD beneficiaries. Since 2001, CMS has published information for consumers about the quality of dialysis care on the Dialysis Facility
Compare website at http://www.medicare.gov
.
Section 153(c) of Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires, among other things, that CMS select measures, develop a scoring methodology, and implement a payment reduction scale that relates to facility performance. A percentage of the facility’s dialysis payment is contingent on the facility’s actual performance on a specific set of measures.
Under AIM 3: Reduce Costs of ESRD Care by Improving Care, the Network shall support the
ESRD QIP, facility performance improvement on QIP measures, and facility data submission for
CROWNWeb, the NHSN, and/or other CMS-designated data collection system(s).
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C.4.3.A. Support for ESRD QIP and Performance Improvement on QIP Measures
C.4.3.A.1. Assist Facilities in Understanding and Complying with QIP Processes and
Requirements
The Network shall assist facilities in understanding and complying with QIP processes and requirements. Network activities shall include, but are not limited to:
Ensuring that all Network staff are fully knowledgeable on ESRD QIP measures and specifications (updated in the Federal Register and on the QualityNet website),
CROWNWeb, NHSN, and other resources available to facilities regarding the QIP
Supporting facilities’ efforts to submit accurate quality data
Encouraging appropriate and timely completion of QIP requirements via
CROWNWeb and/or other CMS-designated mechanisms including, but not limited to, NHSN data submission, attestations regarding the Mineral Metabolism
Monitoring measure, and administration of the ICH CAHPS
Registering provider Master Account Holders to access http://www.dialysisreports.org
or another website designated by CMS to provide
ESRD QIP Performance Score Reports (PSRs) to facilities and provide updated lists of credentialed users to the CMS-designated QIP contractor every quarter.
Notifying facilities of the procedures required to access their QIP PSRs. The
Network shall monitor the PSR access report and contact providers that have not accessed the report within 5 days of the report being made available. The Network shall encourage facilities to review their reports and to submit necessary clarification questions or formal inquiries during the annual 30-day preview period.
Assisting facilities in accessing, printing, and posting the Performance Score
Certificate (PSC) each year within 5 business days of the CMS release date
Informing CMS if a PSC has not been posted.
C.4.3.A.2. Assist Facilities in Improving their Performance on QIP Measures
The Network shall assist facilities in improving their QIP measure rates by performing activities that include, but are not limited to:
Providing technical assistance for any facilities in its service area requesting assistance in quality improvement efforts related to topics addressed by QIP measures including, but not limited to, training providers on these efforts and helping them implement and monitor these quality improvement efforts
Collaborating with stakeholders to achieve improvements on QIP measures on behalf of beneficiaries
Joining existing initiatives/collaboratives identified by the Network or the NCC
(e.g., national or state-level collaboratives focusing on HAI prevention, vaccinations, etc.)
Spreading knowledge and innovations learned in collaboration with facilities
Providing feedback to facilities on areas of improvement for QIP measures based
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on data analysis of QIP measure rates
Educating State Surveyors on monthly calls to ensure that they are knowledgeable about QIP measures and can reinforce with facilities the Network’s education on the QIP
Answering facility questions regarding the ESRD QIP and providing any necessary plain-language materials to aid in their understanding.
C.4.3.A.3. Assist CMS in Monitoring the Quality of and Access to Dialysis Care
The Network shall assist CMS in monitoring the quality of and access to dialysis care as follows:
The Network shall provide feedback to CMS or its designees regarding potential changes in practices reported to or observed by the Network that may adversely impact beneficiaries. Such practice changes include, but are not limited to, changes in access to care and/or the admission or transferring practices of facilities. The
Network shall monitor grievances, clinical data, anecdotal reports, and other sources available to the Network to identify these changes. These monitoring activities and findings shall be reported to CMS in the Monthly Report.
The Network shall enter into a data use agreement (DUA) with the CMSdesignated monitoring and evaluation contractor and share and receive monitoring data as directed by CMS.
If CMS identifies potential and actual adverse impacts on beneficiaries, the
Network shall intervene as directed by CMS to protect patient safety, promote access to care, and ensure that facilities are meeting adequate standard of care.
The Network shall use resources produced by the Learning Network Project contractor as directed by CMS including those intended to improve the consistency of data collection and analysis across Networks.
The Network shall assist CMS in encouraging facilities to report and update data on patient co-morbidities, hemoglobin levels, and anemia management drug dosage via claims.
The Network shall provide facility insight and feedback regarding the QIP to CMS when and in the form requested by CMS.
C.4.3.A.4. Assist Beneficiaries and Caregivers in Understanding the QIP
The Network shall assist beneficiaries and their caregivers in understanding the QIP by performing activities that include, but are not limited to:
Making plain-language information available to beneficiaries and their caregivers regarding the purpose of the QIP, the measures set, and the performance of facilities in the Network’s service area, including producing and distributing PSC educational materials
Being available to answer beneficiary questions regarding the QIP.
The Network shall provide beneficiary insight and feedback regarding the QIP to CMS when and in the form requested by CMS.
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C.4.3.B. Support for Facility Data Submission to CROWNWeb, NHSN, and/or Other
CMS-Designated Data System(s)
The Network shall:
Oversee the timely and accurate submission of data into CROWNWeb using the
CROWNWeb Reports
Resolve out-of-scope patients
Assist with Notifications and Accretions to ensure resolution within 30 days
Serve as a resource for CROWNWeb facility users requiring training, data definitions, submission requirements, etc.
SECTION D – PACKING AND MARKING
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D.1 Packing, Marking and Shipping
All deliverables required under this contract shall be packages, marked and shipped in accordance with Government specifications set forth in Section F of this contract. The
ESRD contractor shall guarantee that all required materials shall be delivered in immediate unable and acceptable condition.
SECTION E – INSPECTION AND ACCEPTANCE
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E.1 FAR 52.252-2 Clauses Incorporated by Reference (Feb 1998)
This contract incorporates one or more clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. Also, the full text of a clause may be accessed electronically at this address:
52.246-4 www.arnet.gov/far/fac.html
Inspection of Services – Fixed Price (August 1996)
E.2 Acceptance by the Contracting Officer Representative
All items to be delivered to the Contracting Officer Representative (COR) will be deemed to have been accepted 45 calendar days after date of delivery, except as otherwise specified in this contract if written approval or disapproval has not been given within such period.
The COR acceptance or revision to the items submitted shall be within the general scope of work in this contract.
E.3 Performance Improvement Plan (PIP)
In the event the ESRD contractor fails to meet its contract requirements for acceptability, a
PIP may be required. (See http://www.cms.gov/manuals/110 )
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SECTION F – DELIVERABLES OR PERFORMANCE
F.1 Period of Performance
The period of performance of the ESRD Network contract is:
Base Year Performance Period:
Option 1:
Option 2:
January 1, 2013 through December 31, 2013
January 1, 2014 through December 31, 2014
January 1, 2015 through December 31, 2015
F.2 FAR 52.217-9 Option to Extend the Term of the Contract (MAR 2000)
This contract may be extended for two (2) option years (Options 1 and 2 as listed above) in accordance with Section I, FAR Clause 52.217-9 “Option to Extend the Term of the Contract.”
The Government may extend the term of this contract by written notice to the Contractor within
60 days; provided that the Government gives the Contractor a preliminary written notice of its intent to extend at least 60 days before the contract expires. The preliminary notice does not commit the Government to an extension.
If the Government exercises this option, the extended contract shall be considered to include this option clause.
The total duration of this contract, including the exercise of any options under this clause, shall not exceed 38 months.
F.3 Schedule of Deliverables
The Network shall submit all required reports and deliverables in accordance with the Delivery Schedule and Reporting Instructions unless otherwise specified by CMS. CMS reserves the right to modify deliverable date by up to 60 days beyond the dates listed in the Delivery Schedule and Reporting
Instructions. CMS CORs, Contracting Officers, or other CMS designees shall authorize the changed deliverable date by listing the new deliverable date in an e-mail to the contractor. Entitled: “Competitive
End Stage Renal Disease Network Statement of Work ”.
Days = calendar days, including holidays
Business days = weekdays, excluding holidays
IAW = in accordance with
DAGC = days after Government comments
ELT = electronically
QTY = quantity
HC = hard copy
CO = Contracting Officer
COR = Contracting Officer’s Representative
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GTL= Government Task Leader
ISSO = Information Systems Security Officer
NCC = Network Coordinating Center
BOD = Board of Directors
MRB = Medical Review Board
NC = Network Council
PAC = Patient Advisory Committee
QIA = Quality Improvement Activity
SA = State Survey Agency
SPOC = Security Point of Contact
Contract period = Base Year or one of two Option Years of period performance
Satisfactory performance under this contract shall be deemed to occur upon delivery and acceptance by the Contracting Officer, or the duly authorized representative, in accordance with the delivery schedule stated below.
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Table F.1. ESRD Network Schedule of Deliverables for the Performance Period of January 1, 2013, through December 31, 2013:
Deliveries or Performance Reports/Items to be Furnished and Delivery Schedule
Notes Type Item Number Item Description Recipient and
Reporting
Mechanism
C.3.1. General Requirements: Internal Quality Control (IQC)
1 Internal Quality ELT to COR
Control (IQC) Plan
ELT to GTL
Due Date(s) Data Source
45 days after the beginning of each contract period, unless otherwise directed by
CMS
Network
C.3.4 General Requirements: Network Organization
2 Identification of NC, ELT to COR
BOD, MRB, and
PAC members ELT to GTL
3 Bylaws
4 Network staffing appropriate to complete the contract
ELT to COR
ELT to GTL
ELT to COR
ELT to GTL
February 1 of each contract period
February 1 of each contract period
February 1 of each contract period
Network
Network
Network
ESRD
Network
Manual
ESRD
Network
Manual
ESRD
Network
Manual
ESRD
Network
Manual
Core
Core
Core
Core
C.3.5 General Requirements: Network Communications
5 Network communications:
ELT to COR
National user-friendly toll-free phone
ELT to GTL
Throughout contract as based on annual
Network ESRD
Network
Manual
Core
Page | 48
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description Recipient and
Reporting
Mechanism
6 number; Network website; NEPOP letter; Investigate undeliverable
NEPOPs
Network educational information:
Patient/provider needs assessment;
Written education plan; Materials provided; Evaluation of efforts and materials
ELT to COR
ELT to GTL
C.3.8 General Requirements: Network Reporting
7 Network committee ELT to COR minutes
ELT to GTL
Due Date(s) Data Source evaluation
Throughout contract as based on annual evaluation
Network
8
9
Monthly Reports
Semi-Annual Cost
Report
ELT to COR
ELT to GTL
ELT to COR
3 business days after any committee
(NC, BOD,
MRB, PAC) meeting
3 business days prior to scheduled monthly meeting/call with COR and GTL
15 th
working day of the 2 nd
Network
Network
Network
Notes Type
ESRD
Network
Manual
Core
Core
ESRD
Network
Manual
Core
ESRD
Network
Core
Page | 49
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
10
11
Draft Annual Report of Network Activities
Final Annual Report of Network activities and publication of approved Annual
Report on Network website
C.3.9 General Requirements: Network Meetings
Recipient and
Reporting
Mechanism
ELT to COR
ELT to GTL
ELT to
Contracting
Officer
ELT to NCC
Due Date(s)
ELT to GTL calendar month after close of each semiannual cost reporting period.
ELT to COR
ELT to GTL
April 30, of each contract period
June 15, of each contract period
Data Source
Network
Network
COR checks
Network website
12 Conduct Post-Award
Meeting with
OAGM/QIG
ELT to COR
ELT to GTL
30 days after the beginning of the contract period, unless otherwise directed by
CMS
Notes
Manual
ESRD
Network
Manual
ESRD
Network
Manual
ESRD
Network
Manual
Network website
Type
Core
Core
Core
Page | 50
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
13 Submit title(s), objective(s), and list of attendees for annual QualityNet conference, LAN meetings, and/ or other conferences
Recipient and
Reporting
Mechanism
ELT to COR
ELT to
GTLGTL
C.3.11 General Requirements: State Survey Agency(ies)
14 Conduct bi-monthly ELT to COR meetings/calls
ELT to GTL
15 Report collaboration with SA(s)
ELT to COR
ELT to GTL
Due Date(s) Data Source
30 days prior to scheduled meetings/ conference
Bi-monthly, except as issues related to quality of care arise
Monthly
Network
Network
Notes
ESRD
Network
Manual
ESRD
Network
Manual
ESRD
Network
Manual
C.3.12 General Requirements: Sanctions
16 Recommend sanctions for recalcitrant facilities
ELT to GTL
ELT to SA as directed by
CMS
C.3.13 General Requirements: Reporting Discrimination
17 Refer suspected discrimination cases to Office for Civil
Rights (OCR) for investigation
ELT to COR
ELT to GTL
ELT to
Monthly CROWNWeb for clinical outcomes;;
NCU for information on
IVD/IVT/failure to place
ESRD
Network
Manual
Report immediately to COR; document in
Monthly
Patient and/or family member/caregiver
ESRD
Network
Manual
Type
Core
Core
Core
Core
Core
Page | 51
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
Contracting
Officer
ELT to OCR
C.3.14 General Requirements: Emergency Preparedness
18
Recipient and
Reporting
Mechanism
Provide Emergency
Plan that cooperates and comply with emergency preparedness duties and KCER
ELT to COR
ELT to GTL
ELT to NCC
ELT to Backup Network
ELT to Backup Network
COR
19 Participate in annual emergency preparedness drill in conjunction with the
NCC
ELT to COR
ELT to GTL
ELT to NCC
Due Date(s) Data Source
Report
15 days after the beginning of the contract period; reviewed quarterly; updated as needed
Copies of the assessment will be sent to the NCC,
GTL, and
COR within 30 calendar days of the completion of the drill.
Network
Network
C.3.16 – 3.18 General Requirements: IT System/Software Maintenance
Notes Type
ESRD
Network
Manual
Core
ESRD
Network
Manual
Core
Page | 52
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
20
21
22
23
Log of daily incremental back-up and weekly full backup Tape
Validation and
Rotation Schedule
Log of offsite storage of back-up media and rotation schedule
List of assigned
Network Information
Technology (IT) staff with required information
Completion of
Remedy ticket assignments
Recipient and
Reporting
Mechanism
ELT as directed by the
CMS
QualityNet
ISSO COR
ELT to CMS
QNet ISSO
ELT as directed by the
CMS
QualityNet
ISSO COR
ELT to CMS
QNet ISSO
ELT as directed by the
CMS
QualityNet
ISSO COR
ELT to CMS
QNet ISSO
Remedy AR
System COR ,
HCQIS
Infrastructure
Contractor
Due Date(s) Data Source
On request
Or
On request Template will be provided by CMS
QNet ISSO; logs maintained locally by IT staff/SPOC
January 24 of each contract period; also, within 5 days of any change to data within the Plan.
As assigned to Network
IT staff through
Remedy
Action
Template will be provided by CMS
QNet ISSO; logs maintained locally by IT staff/SPOC
Template will be provided by CMS
QNet ISSO
Notes
ESRD
Network
Manual
ESRD
Network
Manual
ESRD
Network
Manual
ESRD
Network
Manual
Type
Core
Core
Core
Core
Page | 53
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
24
25
26
Recipient and
Reporting
Mechanism
Due Date(s)
Maintenance of systems and software in compliance with applicable configuration requirements
Update Remedy inventory for all procured and received
Government Property
(including hardware and software)
Maintain HHS-22 process within
Remedy
List of all purchased and leased equipment in HHS-565 submission Final
Memorandums or Remedy AR
System COR,
HCQIS
Infrastructure
Contractor
Submit HHS-
22 for approval via
Remedy; updated record in Remedy
Inventory
Module. COR,
CMS
Government
Property
Administrator
ELT to CMS
Government
Property
Administrator
Request (AR)
System
Must be completed within the designated timeframe
As released
As required
(i.e., when
Government
Property
(including hardware and software) is received)
October 31 of each contract period or upon request,
Data Source Notes Type
Core
Core
Core
Page | 54
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
27
C.3.18 General Requirements: Network Security
28 Network System
Security Plan (SSP)
29
Report
Update Remedy inventory for all
Government Property
(including hardware and software) transferred. Maintain
HHS-22 process within Remedy and Information
Security (IS) Risk
Assessment (RA)
Recipient and
Reporting
Mechanism
ELT to
Contracting
Officer
Submit HHS-
22 for approval via
Remedy; update record in Remedy
Inventory
Module to
COR, CMS
Government
Property
Administrator
ELT to CMS
QNet ISSO
Business Continuity and Contingency Plan
(BCCP) that demonstrates how the organization shall establish, maintain,
ELT as directed by the
CMS QNet
ISSO COR
ELT to CMS
Due Date(s) upon contract termination or normal contract conclusion
As required
(i.e., when
Government
Property
(including hardware and software) is transferred, retired or disposed)
May 28 of each contract period; also, within 15 days of any change
May 28 of each contract period; also, within 15 days of any change
Data Source
Template will be provided by CMS
QNet ISSO
Template will be provided by CMS
QNet ISSO
Notes
ESRD
Network
Manual
ESRD
Network
Manual
Type
Core
Core
Core
Page | 55
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
30
31 and effectively implement plans for emergency response, back-up operations, and post-disaster recovery for organizational information systems to ensure the availability of critical information resources and continuity of operations in emergency situations
Daily record of visitors (i.e., personnel external to the Network)
List of active and inactive QNet user accounts with required data
Recipient and
Reporting
Mechanism
QNet ISSO
ELT as directed by the
CMS QNet
ISSO to COR
ELT to CMS
QNet
QualityNet
ISSO
ELT as directed by the
CMS QNet
QualityNet
ISSO to COR
ELT CMS
Due Date(s)
Upon request Logs maintained locally by IT staff/SPOC; template will be provided by CMS
QNet ISSO
January 24 of each contract period, certification; also, within 5 days of any change to
Data Source
Logs maintained locally; template will be provided by CMS QNet
ISSO
Notes
ESRD
Network
Manual
ESRD
Network
Manual
Type
Core
Core
Page | 56
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
32
33
34
QNet Security
Awareness Training
(SAT)
QNet Security
Awareness Training
(SAT) Certification
Letter
Record of security incident response
Recipient and
Reporting
Mechanism
QNet
QualityNet
ISSO
ELT to QNet
Security Team
ELT as directed by the
CMS
QualityNet
ISSO COR
ELT to CMS
QNet
ISSOCOR
QNet
ELT to CMS
QNet ISSO
Submit additional artifacts on request.
Submit
Incident
Report in
Remedy AR; submit artifacts; ELT as directed by
Due Date(s) Data Source data; or upon request.
Before
Network employee receives a
QNet User
Account and on request
April 30 of each contract period
Monthly; also, as required (i.e., when a security incident occurs)
Logs maintained locally by IT staff/SPOC with required data and artifacts; templatewill be provided by CMS
QNet ISSO
Template will be provided by CMS
QNet ISSO
Template will be provided by CMS
QNet ISSO
Notes
ESRD
Network
Manual
ESRD
Network
Manual
ESRD
Network
Manual
Type
Core
Core
Core
Page | 57
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description Recipient and
Reporting
Mechanism the CMS
QNet ISSO to
CMS QNet
ISSO and
QNet Security
Team
C4.1A. AIM 1: Beneficiary and Family Engagement
35 Attendance by 1 ELT to COR
Patient SME/family member/caregiver at
Network’s annual evaluation and other
CMS meetings as directed
ELT to GTL
36
37
Develop Marketing
Plan for engagement of beneficiaries and families/caregivers at the facility level
Develop a report of synthesis of activities and learning of this activity in preparation for next contract year
ELT to COR
ELT to GTL
ELT to COR
ELT to GTL
38 Develop Patient
Learning and Action
Network Plan
ELT to COR
ELT to GTL
Due Date(s) Data Source
At Network evaluation and as required
30 calendar days from start of contract period
November
30, 2013
November
30, 2014
(Option Year
1)
30 calendar days from start of contract
Notes Type
Signed affidavit required
Core
Core
Core
Core
Page | 58
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
39
40
41
42
Provide 20% of facilities located in the Network area with patient representative forms to identify 10 patients to participate in activities
Identify at least 10
Patient Subject
Matter Experts to serve as patient representatives on the
Network Patient
Engagement LAN and NCC Patient
LAN
Provide meeting minutes of Patient
Engagement LAN, highlighting Patient
Subject Matter
Experts’ contributions
Identify 3 of the 10
Patient Subject
Matter Experts to participate in designing QI projects/spreading practices and
Recipient and
Reporting
Mechanism
Due Date(s) Data Source
ELT to COR
ELT to GTL
ELT to NCC
ELT to COR
ELT to GTL
ELT to NCC
ELT to COR
ELT to GTL
ELT to NCC
ELT to COR
ELT to GTL
ELT to NCC period
February 1 of each contract period
March 1of each contract period
Within 15 days of each of required meetings
March 1,
2013
March 3,
2014 (Option
Year 1)
Notes Type
Patient
SME participation form; ESRD
Network
Manual
Core
ESRD
Network
Manual
Core
ESRD
Network
Manual
Core
ESRD
Network
Manual
Core
Page | 59
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
43
Recipient and
Reporting
Mechanism development of at least two of the identified campaign or education materials and to serve on a national level as representatives on the
NCC Patient LAN
Implement a QI project developed by the LAN that promotes patientcentered care and protects the interest of beneficiaries
ELT to COR
ELT to GTL
44 Implement two campaigns developed by the LAN which impact at least 20% of the Network population per campaign
ELT to COR
ELT to GTL
Due Date(s) Data Source
March 4,
2015
(Option Year
2)
June 30, 2013
(Base
Contact)
March 31,
2014 (Option
Year 1)
March 31,
2015
(Option Year
2)
June 30, 2013
(Base
Contact)
March 31,
2014
(Option Year
1)
March 31,
2015
Notes Type
ESRD
Network
Manual
Performance
ESRD
Network
Manual
Performance
Page | 60
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
45 B&FE Monthly
Report, to include:
Attendance by 1 patient SME/Family member in 1 COR monthly monitoring meeting per quarter
Documentation of implementation of
Marketing Plan
Documentation of
Patient LAN Plan
Documentation of collaboration with
SA(s) to facilitate patient engagement
Invitation of 3 of 10
Patient SMEs to each of 4 Network meetings
Documentation of maintenance of patient participation/activities in Patient LAN
If Network makes any on-site visits, document compliant
Recipient and
Reporting
Mechanism
Due Date(s) Data Source
ELT to COR
ELT to GTL
(Option Year
2)
Monthly of each contract period
Notes Type
Core
Page | 61
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description Recipient and
Reporting
Mechanism with C.4.1.A
C.4.1.B.1. Evaluate and Resolve Grievances
46 Enter grievance data into Network Contact
Utility (NCU) or other CMSdesignated system
ELT to COR
ELT to GTL
Due Date(s) Data Source
Within 1 day of receipt of grievance
NCU or other
CMS-designated system
47
48
49
50
Conduct grievance review and document procedures for resolution and document if the grievance was resolved to the satisfaction of the patient
Report statistics on grievance case reviews
Networks will ensure that 100% of all beneficiary data for filed grievances be submitted to the
NCC.
Achieve at least 80% of Satisfaction Survey respondents with
Satisfied or Very
ELT to COR
ELT to GTL
ELT to COR
ELT to GTL
ELT to COR
ELT to GTL
ELT Survey contractor
Within 30 days of receipt of grievance, reported monthly
Monthly of each contract period
Monthly of each contract period
NCU
At evaluation Dashboard
Notes
ESRD
Network
Manual
ESRD
Network
Manual
ESRD
Network
Manual
Network provides data to survey
Type
Core
Core
Core
Core
Performance
Page | 62
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
51
52
Recipient and
Reporting
Mechanism
Satisfied responses
Perform Quality of
Care Reviews
Perform focused audit to identify systemic issues and trends
ELT to COR
ELT to GTL
ELT to SA (as needed)
ELT to COR
ELT to GTL
Due Date(s) Data Source
As needed or as instructed by CMS
53 ELT to COR
ELT to GTL
March 1,
2013 of each contract period
October 1 of each contract period
April 2 of contract period
NCU
NCU
54
Identify one grievance trend to address in five facilities with the highest number of grievances in that trend area and develop a QIA
Provide impact analysis of interventions
May 1 st
of each contract period June
1 st
of each contract period
August 1 of each contract
Notes contractor
ESRD
Network
Manual
Type
Core
ESRD
Network
Manual
Core
ESRD
Network
Manual
Performance
Core
Page | 63
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description Recipient and
Reporting
Mechanism
Due Date(s)
55
56
Contact SA(s)SA to coordinate management of a response plan to resolve patient issue
Provide Ombudsman
Report
ELT to COR
ELT to GTL
ELT to COR
ELT to GTL period.
October 1 of each contract period
Within 2 days of identified issue or trend, as needed
February 13 of each contract period
C.4.1.B.2 Support ICH CAHPS
57 Notify providers of
ESRD QIP requirements for ICH
CAHPS survey completion
58 Track ICH CAHPS participation by facilities
ELT to COR
ELT to GTL
59 At CMS direction, develop and implement CAPHS
QIA
ELT to COR
ELT to GTL
C.4.1.C.1 Assess Involuntary Discharges/Involuntary Transfers
60 Initiate investigations into any IVD/IVT; document
ELT to COR
ELT to GTL
ELT to COR
ELT to GTL
April 2 of each contract period
TBD
Within 24 hours of reported
Data Source
Dashboard
NCU
Notes Type
ESRD
Network
Manual
Core
ESRD
Network
Manual
Core
ESRD
Network
Manual
Core
Performance
ESRD
Network
Manual
Performance
ESRD
Network
Manual
Core
Page | 64
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
61
Recipient and
Reporting
Mechanism characteristics of patients, including race, ethnicity, new
ESRD versus established patients
Track performance on
IVD/IVT occurrence and investigations
ELT to COR
ELT to GTL
Due Date(s) Data Source
IVD/IVT.
Report
Monthly of each contract period
Report
Monthly of each contract period
C.4.1.C.2 Patients at Risk for IVD/IVT and Failure to Place
62 Initiate investigations ELT to COR into any incidences of failure to place for a new or established
ELT to GTL patient; document characteristics of patients, including race, ethnicity, new
ESRD versus established patients
63 Track performance on avoidance of
IVDs/IVTs/failures to place and
ELT to COR
ELT to GTL investigations
C.4.1.C.3. Generate Regular Access to Dialysis Care Report
64 Provide Access to
Dialysis Care Report
ELT to COR
ELT to GTL
C.4.1.D. Vascular Access Management
Monthly of each contract period and within 24 hours of reported
IVD/IVT
Monthly of each contract period
Monthly of each contract period
NCU
NCU
Notes
ESRD
Network
Manual
ESRD
Network
Manual
Type
Performance
Core
ESRD
Network
Manual
Performance
ESRD
Network
Manual
Core
Page | 65
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
65
66
67
68
For AVF-in-use rate, meet performance requirements specified by SOW
Using the October data of the prior calendar year as a baseline, improve AV fistula rate for prevalent patients by reducing quality deficit by 20%, unless the expected improvement is less than the floor of 1.0 percentage point or greater than the ceiling of 4.0 percentage points, in which case the floor or ceiling shall apply
For >90 day catheter use, meet performance requirements as specified by SOW
Using the October data of the prior calendar year as a baseline, achieve a
Recipient and
Reporting
Mechanism
ELT to COR
ELT to GTL
ELT to COR
ELT to GTL
ELT to COR
ELT to GTL
ELT to COR
ELT to GTL
Due Date(s) Data Source
Monthly of each contract period
By
October15 of each contract each period
Monthly of each contract period
By October
15 of each contract year
Dashboard
Dashboard
Dashboard
Dashboard
Notes Type
Performance
ESRD
Network
Manual
Performance
ESRD
Network
Manual
Performance
Performance
Page | 66
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description Recipient and
Reporting
Mechanism
69 goal of 2 percentage point reduction in use of catheters >90 days for prevalent patients in facilities with baseline rates higher than 10%
Support 100% of applicable dialysis facilities in submission of vascular access data
ELT to COR
ELT to GTL
C.4.1.E. Reduction of Healthcare Acquired Infections
70 Provide a report on ELT to COR the consultation with local stakeholders, ELT to GTL
71 including QIOs working on HAI initiatives
Convene a workgroup with facility participation and develop a framework for HAI LAN
ELT to COR
ELT to GTL
72 Obtain group administrator rights from each facility
ELT to COR
ELT to GTL
Due Date(s) Data Source
Monthly
April 1 of each contract period, then report progress monthly
No later than
April 1 of each contract period, then report progress monthly
February 1 of each contract period, then report
Dashboard
Notes Type
ESRD
Network
Manual
Core
ESRD
Network
Manual
Core
ESRD
Network
Manual
Performance
Core
Page | 67
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
73
74
75
76
Educate facilities on the framework of
NHSN enrollment
Recipient and
Reporting
Mechanism
Due Date(s) Data Source
ELT to COR
ELT to GTL
ELT to COR
ELT to GTL progress monthly
Monthly
Progress reported of each contract period
December 31 of each contract period
>080 % of facilities enrolled in and reporting to NHSN for at least 6 consecutive months by December 31,
2013
For enrollment and reporting of data in
NHSN, meet performance requirements as specified by SOW
At CMS’ direction, develop and implement a QIA based on infection data obtained from the NHSN database that impacts at least
20% of the Networkarea facilities
ELT to COR
ELT to GTL
ELT to COR
ELT to GTL
Progress reported monthly of each contract period
Monthly
Progress reported of each contract period
Dashboard
Dashboard
Notes Type
ESRD
Network
Manual
Core
ESRD
Network
Manual
Performance
Performance
Performance
Page | 68
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description Recipient and
Reporting
Mechanism reporting Dialysis
Facility Event data, with a minimum of
5% of the Network population included
C.4.2.A. AIM 2: Innovation Projects
77 Identify AIM 2
Innovation Pilot
Project topic and
78 disparity
Demonstrate improvement as required for the AIM
2 Innovations Pilot
ELT to COR
ELT to GTL
ELT to COR
ELT to GTL
Project including implementation of disparity reduction.
Network may choose any of five (5) projects, with a requirement that all measures within the project must achieve the designated outcome as specified in C.4.2
C.4.3. AIM 3: Reduce Costs of ESRD Care by Improving Care
79 Document training of
Network staff on
ELT to COR
ESRD QIP measures, ELT to GTL
Due Date(s) Data Source
February 15 of each contract period
Monthly
Progress reported of each contract period
Monthly of each contract period
Dashboard
Notes Type
Core
Performance
Core
Page | 69
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
80
Recipient and
Reporting
Mechanism measure specifications,
CROWNWeb, and resources available to facilities
QIP Monthly
Activities Report, to include:
Technical assistance provided to support
QIP requirements related measures, number of facilities assisted, and efforts to ensure timely/appropriate data by facilities
Facility assistance with accessing, posting, and printing
QIP PSR as requested
Document participation in any existing collaborative identified by Network or NCC for QIP activities
Document activities to spread best practices/innovations
ELT to COR
ELT to GTL
Due Date(s) Data Source
Monthly of each contract period
Notes Type
Core
Page | 70
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
81
82
83
Recipient and
Reporting
Mechanism learned from QIP activities
Provide feedback information on areas of QIP to facilities
Provide documentation of facilities intervention as directed by CMS on QIP information to dialysis patients
Document QIPrelated topics on monthly calls with
SA(s)
Provide feedback of
QIP measure impact on patients
Notify facilities to review their QIP
Performance Score
Report (PSRs) during the -day30- open period
Register provider master account holders to access the
QIP score accounts
Provide updated
MAH lists for
ELT to COR
ELT to GTL
ELT to COR
Due Date(s) Data Source
Within 5 days of score release
Ongoing
Quarterly of each contract
Notes Type
ESRD
Network
Manual
Core
Core
Core
Page | 71
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description credentialed users
Recipient and
Reporting
Mechanism
ELT to GTL
ELT to QIP contractor
ELT to COR
ELT to GTL
84
85
Identify intervention(s) to work with stakeholders in implementing or impacting State Plans related to achieving
QIP performance measure outcomes.
Obtain DUA with
CMS QIP monitoring and evaluation contractor
ELT to COR
ELT to GTL
86 Document use of
LAN resources in
QIP activities
ELT to COR
ELT to GTL
C.4.3.B. Support facility data submission for CROWNWeb
87 Provide documentation of number of out-of-
ELT to COR
ELT to GTL
88 scopes patients resolved
Use CROWNWeb data to provide technical assistance to
ELT to COR
ELT to GTL
Due Date(s) Data Source period
Progress reported quarterly of each contract period
February 15 of each contract period
Monthly of each contract period
Monthly of each contract period
Within 7 days of monthly review of
NCC
CROWNWeb
CROWNWeb
Notes
ESRD
Network
Manual
Core
ESRD
Network
Manual
ESRD
Network
Manual
Type
Core
Core
Core
Core
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End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item Number Item Description
89
Recipient and
Reporting
Mechanism facilities not submitting data on
QIP measure rates, including attestation of NHSN, into
CROWNWeb in a timely and accurate manner
Assist CROWNWeb facility users with resources for training, data definitions, submission requirements, etc.
ELT to COR
ELT to GTL
Due Date(s) Data Source
CROWNWeb
Reports in each contract period
As needed CROWNWeb
Notes
ESRD
Network
Manual
Type
Core
Table 2 – Conflict of Interest Schedule of Deliverables: ESRD Network Schedule of Deliverables for the Performance Period of
January 1, 2013, through December 31, 2013
Page | 73
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item
No.
Item Description Recipient and
Reporting
Mechanism
Due Date(s)
Conflict of Interest Identification
1
2
3
Submission of proposed contract or other agreement with provider of services or health plan for services related to the proposed provider or health plan’s Medicare reimbursement
Contracting
Officer and
Conflict of
Interest
Specialist
ELT
COR/GTL
At least 30 days prior to the planned execution date of the agreement
H.11.C.3(c)
Submission of report listing the agreements entered into with a provider of services or health plan and with federal, state or local government agencies
H.11.3.C.3 (d)
Submission of documentation that
Contracting
Officer and
Conflict of
Interest
Specialist
ELT
COR/GTL
Contracting
Officer and
June 28, 2013
At least 30 days prior to the planned execution date
Data Source Evaluation
(of Deliverable)
Notes
Page | 74
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item
No.
Item Description Recipient and
Reporting
Mechanism
Network’s subcontractors have
Conflict of
Interest mitigated any conflict or potential conflict
Specialist
ELT
COR/GTL
H.11.C.4
Due Date(s) of the agreement
Conflict of Interest Disclosure
4
5.
Submit Organizational
Conflicts of Interest
Certificate in accordance with
H.11.D.1 and H.11.D.2
(a)
Submit Ownership
Interest Information
H.11.D.1(g)
Contracting
Officer and
Conflict of
Interest
Specialist
ELT
COR/GTL
ELT
COR/GTL
Upon submission of technical proposal
Upon request for revisions from CO
Updates included in June
28, 2013 report
45 days before any change in the information submitted in accordance
H.4.2
With Technical Proposal
Updates included in June
28, 2013 report
Personnel Changes Requiring Conflict of Interest
6. Submission of resume Contracting Prior to engaging the
Data Source Evaluation
(of Deliverable)
Notes
Page | 75
End Stage Renal Disease Network
CMS-2012-ESRD-FFPRENEWAL
Item
No.
Item Description Recipient and
Reporting
Mechanism or CV and additional information in
Officer and
Conflict of accordance with paragraph H.11.F
Interest
Specialist
ELT
COR/GTL
Start-Ups, Acquisitions and Affiliations
7. Provide notification of Contracting intent to start-up Officer and acquire or affiliate with or be acquired by
Conflict of
Interest another business
Specialist
H.11.G
ELT
COR/GTL
Due Date(s) services of the replacement personnel in accordance with paragraph H.6
As soon as possible but no case later than 60 days before the projected start up date
Data Source Evaluation
(of Deliverable)
Notes
Page | 76