Attachment J-10.docx

Attachment J.10 ESRD NETWORK EVALUATION REPORT BASE CONTRACT (2010 – 2011)

NETWORK _________________________ DATE _____________________

ESRD NETWORK EVALUATION BASE CONTRACT (2010 – 2011)

NETWORK _________________________ DATE _____________________

Task 1. Quality Improvement

· The Network assisted ESRD facilities in assessing and improving the care provided to all individuals with ESRD.

· The Network Quality Improvement Program contained all four components:

1. Vascular Access (Fistula First) Quality Improvement Project;

2. Clinical Performance Measures (CPMs) Project;

3. Network-Specific Quality Improvement Projects (QIPs);

4. Facility-Specific Quality Assessment and Improvement Projects (QAIPs).

· The Network reflected these projects in a comprehensive Quality Improvement Work Plan developed in conjunction with its Medical Review Board (MRB).

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Task 1.a Vascular Access Quality Improvement Projects

QI.1.a #1 The Network has improved the rate of fistula use in prevalent patients using a quality deficit reduction approach:

· Baseline (3/31/2009): ________

· % improvement required: _____

· Network contract goal: _______

· Network current rate based on March data (3/31/2010) released (5/12/2010) : _______________

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QI.1.a #2 The Network collected data from 100% of facilities not excluded for tracking and monitoring AV Fistula rate.

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QI.1.a #3 The Network implemented QIPs in the area of vascular access with facilities in the Network area.

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QI.1.a #4 The Network monitored the progress of the QIPs using QI processes and rapid cycle improvement:

· Established a baseline;

· Set a goal for improvement;

· Set measurement/re-measurement criteria;

· Assessed/reassessed achievement of goal;

· Identified barriers to improvement.

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QI.1.a #5 The Network enhanced, utilized, and incorporated the newly developed resources by the Fistula First Contractor (Network 5).

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QI.1.a #6 The Network undertook educational activities and provided technical assistance to enhance facilities’ fistula placement, patency, and functionality rates, including providing facilities with training materials on:

· Cannulation;

· AVF maintenance;

· Monitoring.

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QI.1.a #7 The Network trained dialysis facilities (including onsite training) on cannulation, maintenance and monitoring of AV fistulas, and/or other measures that support Fistula First or catheter reduction.

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QI.1.a #8 The Network participated with the Fistula First Contractor (Network 5) in meetings and actively engaged in one or more of the following activities:

· Monthly meetings;

· Member of coalition subgroup;

· Participated with the Technical Expert Panel (TEP).

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QI.1.a #9 The Network collaborated with its partners to:

· Promote utilization of vascular access quality improvement programs, tools, and activities;

· Achieve ESRD treatment changes at a system level;

· Influence effective hospital discharge planning to enable early placement of fistulae.

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Task 1.b. Clinical Performance Measures(CPMs) Project

QI.1.b #1 The Network provided clinical performance information to facilities based on Electronic Laboratory Data Reports (ELab) to stimulate improvement in patient care, practice patterns, processes, and outcomes for the targeted patient population.

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QI. 1.b #2 The Network utilized the reported ELab data to:

1. Analyze practice patterns, processes, and outcomes of care for the targeted patient population;

1. Analyze conformance to clinical practice guidelines;

1. Provide facilities with information to stimulate improvement in patient care.

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QI. 1.b #3 The Network developed and conducted QIPs based upon one or more of the established set of CPMs for:

· Adequacy of dialysis;

· Anemia management;

· Vascular access in the area of decreasing catheter use and/or stenosis monitoring.

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Task 1.c. Network-Specific Quality Improvement Projects

QI.1.c. #1 The Network worked with the MRB and one or more of the following partners to develop one or more specific QIPs that advance the purpose and strategic goals of the ESRD Network Program and are directly aligned with the areas of most need and potential impact within the Network area:

· Patient Advisory Committee;

· QIO(s);

· Providers/facilities;

· Affiliations and associations;

· Beneficiary groups;

· Renal advocacy groups

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QI.1c #2 The Network included the following details in its QIP documentation:

· Project name;

· Baseline measurement;

· Remeasurement criteria and status;

· Analysis of sustainability.

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QI.1c #3 The Network QIP activities reflect identified Network-wide needs and are tailored to specific target areas, such as a geographic area, provider group, or domain of care.

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QI.1c #4 The Network undertook activities in at least one of the following pre-approved areas:

· Adequacy of dialysis-hemodialysis;

· Adequacy of dialysis-peritoneal;

· Anemia management;

· Vascular Access;

· Nutrition status;

· Hemodialysis reuse;

· Patient experience of care;

· Complaints/grievances;

· Patient safety;

· Infection control;

· Immunizations;

· Bone disease;

· Transplantation;

· Measures/indicators to promote self-care;

· Encouragement of vocational rehabilitation, volunteerism, and/or employment;

· End of life care planning.

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Task 1.d Facility-Specific Quality Assessment and Improvement Projects (QAIPs)

QI.1.d #1 The Network assisted facilities in the development and implementation of Quality Assessment and Improvement Projects aimed at improving patient care processes and outcomes.

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QI.1.d #2 The Network identified individual facility poor performance based upon request from one or more facilities or utilizing information from any of the following:

· ELab data;

· Other data reports;

· Analysis of complaint/grievance information;

· Results of a SSA or other federal compliance survey;

· Patient survey;

· Other types of investigation.

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QI.1.d #3 The Network, in responding to local needs, collaborated with one or more of the following:

· Network MRB;

· Network Council;

· ESRD facilities/facility owners;

· LDOs;

· Patient organizations;

· Medicare Advantage Organizations;

· Renal-related professional organizations;

· QIO(s);

· SSA(s);

· Other ESRD Networks;

· CMS.

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QI.1.d #4 The Network activities assisted in facility-level development, implementation, maintenance, and evaluation of an effective data-driven, interdisciplinary QAPI that focused on improved processes of care and health outcomes.

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QI.1.d #5 The Network utilized one of the following methods to achieve the objective in QI.1.d.#4 above:

· Fostered internal quality improvement at the facility level;

· Provided technical assistance;

· Provided education;

· Encouraged and supported focused local quality initiatives.

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Task 1.e Quality Improvement Work Plan (QIWP)

QI.1.e. #1 The Network developed a QIWP in conjunction with the Medical Review Board (MRB). This is evidenced by:

· Minutes from the MRB meeting;

· Signature of MRB Chair on the QIWP.

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QI.1.e #2 The Network submitted the QIWP no later than 60 calendar days after the beginning of the contract year.

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QI.1.e #3 The Network addressed all elements, including measurement and remeasurement for each activity and ensured that they were;

· Designed using available data sources;

· Demonstrated use of rapid cycle evaluation and adjustment.

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QI.1.e. #4 The Network submitted, no later than 60 working days after receipt of ELab clinical data, a revised QIWP that assessed and adjusted the prioritized improvement activities under Task 1.b. These QI projects included quantitative targets for clinical outcome improvement and included the following:

Project name:_______________ Baseline measure:____________ Remeasurement: ____________ Sustainability: _______________

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Task 2 Community Information and Resources

· The Network established and maintained a procedure for receiving, evaluating, resolving, and tracking patient complaints and grievances;

· The Network established or maintained a national user-friendly toll-free number to facilitate communication with patients within the Network area;

· The Network developed and/or maintained a Network Web site that is 508 compliant and follows CMS standards and guidelines;

· The Network complies with laws that prohibit excluding individuals with disabilities or denying them the opportunity to receive the same information and assistance provided to other patients without disabilities.

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Task 2.a Provision of Education Information – New Patients

CIR.2.a. #1 The Network provided the NCC with the Network letter, on Network letterhead, to be included in the New ESRD Patient Orientation Package (NEPOP) sent to new ESRD patients in the Network area.

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CIR.2.a. #2 The Network letter included all of the following:

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· Information on the Network’s grievance procedure;

· Other Network-specific information, including :

· Network’s toll-free number;

· Services and assistance offered;

· A way to request/obtain additional education materials on ESRD;

· ESRD related patient care;

· Treatment options.

· Information about the function of the State Survey Agency, to include addresses and phone numbers of each SSA in the Network area and the fact that the SSA receives and investigates complaints and grievances.

CIR.2.a #3 The Network followed-up on all returned mail to the NCC when NEPOPs were undeliverable. The Network:

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· Determined whether patient was deceased or was still alive and had a current address;

· Provided the NCC with the patient’s name and current address;

· Updated its patient database in CMS’ designated Information System;

· Reported monthly to the NCC the number of returns due to death and address changes.

· As a part of the NW IQI process determined an acceptable NEPOP return rate and monitored/tracked and intervened as appropriate.

Task 2.b Provision of Educational Information – Patients

CIR.2.b #4 The Network has a written plan for making informational materials available to patients in its service area based on the following:

· Determination of the most effective strategies for the distribution of informational materials;

· Utilization of the basic principles of marketing and consumer engagement;

· In-depth knowledge of the demographics and educational needs of the Network’s patient population.

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CIR.2.b#5 The Network made available, at a minimum, the following information to patients, and annually informed patients on how to contact the Network to obtain the information (the methods used must have the potential to reach all patients):

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· The role of the ESRD Network;

· The Network’s process for receiving, reporting, resolving, and tracking patient complaints and grievances;

· Treatment options and new ESRD technologies;

· 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;

· Information on vascular access;

· Information on state/regional vocational rehabilitation programs available in the Network area;

· The Network’s user-friendly toll-free phone number;

· The address for the Network’s Web site, which is 508 compliant and contains the Network grievance process, the location of the Network, the toll-free number for patients, the current Annual Report, the Network goals, and a link to Dialysis Facility Compare;

· Information on how to access and use Dialysis Facility Compare;

· Information on the Patient Advisory Committee and how to join;

· Information on the importance of immunization;

· Information on Medicare Part D benefits and how to enroll.

CIR.2.b #6 The Network utilized information that was already available and distributed information through the most effective and efficient approaches possible.

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CIR.2.b#7 The Network utilized any of the following communication vehicles to educate patients about its complaint and grievance process:

· Posters;

· Newsletters;

· Videos;

· Workshops;

· Mailings.

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Task 2.c Provision of Educational Information – Providers/Facilities

CIR.2.c #8 The Network made available, at a minimum, the following new or revised information to the facilities in its Network area with a directive to make the information available to patients or inform patients on how to contact the Network to obtain the information:

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· The Network’s Annual Report, which contains the Network’s goals, activities, and plans for monitoring compliance;

· Regional and national patterns/profiles of care;

· Network QIP results;

· Information on the importance of immunizations;

· Other materials that providers/facilities can use in their quality improvement programs;

· Information on how to access and use Medicare’s Dialysis Facility Report;

· Information on the availability of VISION, CROWNWeb, and other electronic information systems developed by CMS.

CIR.2.c #9 Additionally the Network did all of the following:

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· Conducted special mailings as requested (up to two per year);

· Printed and distributed Dialysis Facility Reports annually;

· Distributed information regarding Federal Drug Administration alerts, recalls, etc.

CIR.2.c #10 The Network sought and used information that is already available and distributed information through the most effective and efficient approach possible.

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Task 2.d Provision of Technical Assistance

CIR.2.d # 11 The Network provided technical assistance:

· Upon request of the provider;

· Based upon identified opportunities to improve care;

· When poor performance or problems were indentified; and

· As otherwise directed by CMS.

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CIR.2.d # 12 The Network conducted the following activities:

· Identified available providers and/or facilities for patients seeking ESRD services (including transient and disaster displaced patients seeking ESRD services);

· Referred those patients seeking ESRD services to the Dialysis Facility Compare Web site for additional information;

· Assisted individuals with ESRD in understanding the information on Dialysis Facility Compare;

· Educated dialysis facility professional staff regarding the use of information on Dialysis Facility Compare;

· Assisted facilities in developing procedures to assess patients for placement in treatment modalities that improve independence, quality of life, and rehabilitation;

· Provided patient education regarding kidney transplantation, home therapies, and in-center self-care;

· Promoted patient education regarding immunizations;

· Assisted providers/facilities to make timely patient assessment, thereby promoting timely kidney transplant referrals;

· Addressed impediments to referrals and/or transplantation;

· Provided education regarding the importance of appropriate advance care planning and assisted in development of effective tools to encourage advance planning;

· Assisted providers/facilities in establishing and promoting rehabilitation goals for referring suitable candidates to vocational rehabilitation programs and/or such programs or activities that enhance independence and quality of life;

· Assisted providers/facilities in developing appropriate quality improvement plans;

· Assisted facilities in developing plans for local disasters;

· Assisted providers/facilities in developing mechanisms for assessing the health-related quality of life of patients;

· Assisted providers/facilities in developing community and patient education programs.

CIR.2.d #13 Annually, the Network informed facilities/providers and patients that it was available to provide technical assistance upon request.

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Task 2.e. Emergency/Disaster Preparedness and Response

CIR.2.e # 14 The Network has a written emergency and disaster plan addressing continuity of Network operations, its role and function relative to the dialysis facilities located in its service area, its role in national disasters, and adherence to all of the elements listed in CIR.2.e # 15 and 16.

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CIR.2.e # 15 The Network established a partner relationship with another Network to provide back-up assistance and has a written back-up agreement that clearly articulates the structure and process for the transfer of duties and responsibilities in a time of emergency/disaster.

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CIR .2.e # 16 The Network’s Emergency and Disaster Plan includes its Business Continuity and Contingency Plan.

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CIR. 2.e #17 The Network demonstrated its ability to do all of the following:

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· Assist facilities with emergency planning ;

· Assist facilities in developing plans for local emergencies/disasters.

· Maintain a phone system to ensure that the Network staff members can be contacted as necessitated by the emergency/disaster;

· In the event of local disaster, track availability of services;

· Assist patients in identifying dialysis facilities that can provide ESRD services;

· Track and make available to the public the open and closed status of the facilities in the affected area;

· Provide information to family members and treating facilities on where a patient previously/currently is receiving services to assist in location of individuals and the exchange of critical medical information;

· As necessary, participate in national and/or regional calls with providers, emergency workers, and other essential persons;

· As appropriate, coordinate activities with providers and other emergency workers to ensure access to dialysis;

· As directed by CMS, assist other Networks in carrying out contract requirements during the initial and recovery phase of an emergency/disaster.

Task 2.f Coalition

CIR.2.e #18 The Network shall actively engage in efforts to support the development and/or maintenance of a strategic coalition within the renal community in the Network area through training and ongoing consultative support.

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CIR.2.e #19 The Network met all of the following requirements:

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· When a coalition does not already exist; identify a coalition focus, with PO approval, and recruit key partners, including some with which the Network does not conduct routine business;

· Assembled and/or sustained a coalition of key partners;

· Supported the establishment of a vision, mission, goal(s), and operating procedures jointly agreed to by coalition members;

· Promoted information exchange and collaboration among members aimed to enhance each other’s capacity;

· Held coalition meetings with established agenda and recorded and distributed meeting minutes to coalition members;

· Identified and recruited key partners and actively participated in coalition activities;

· Built partnerships with new entities; expanded and enhanced existing partnerships;

· Created greater ownership among coalition partners;

· Utilized, within CMS conflict of interest guidelines, other available resources by having coalition partners bring resources to the table or identify others with resources;

· Engaged in innovative problem solving by collaborating with coalition partners on jointly shared problems.

Task 2.g. Complaints and Grievances

CIR.2.g #20 The Network proactively identified, prevented, processed and resolved patient, provider, and/or facility complaints and grievances.

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CIR.2.g #21 Developed Network-specific policies, procedures, and standards for receiving, processing, investigating, resolving, documenting, and reporting patient, provider, and/or facility complaints and grievances.

CIR.2.g #22 The Network conducted trend analysis of reported situations.

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CIR.2.g #23 The Network provided dialysis facilities with resources and educational programs under the Decreasing Dialysis Patient-Provider Conflict Initiative.

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CIR.2.g #24 Described in the CMS-designated system, in a narrative format, the Network’s actions and intervention to resolve patient and provider/facility complaints/grievances, which included:

· Information on the nature of the complaints/grievances;

· Actions taken to resolve complaints/grievances; and follow-up.

CIR.2.g #25 Provided aggregate, quantitative information on types of complaints, grievances, involuntary discharges, and patient/providers/facility inquires/concerns.

CIR.2.g. #26 The Network described and reported in the Quarterly Report patient and facility complaints/grievances and Network actions and interventions.

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CIR.2.g #27 Quarterly, at a minimum, the Network analyzed facility-specific data to identify patterns of concerns.

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CIR.2.g #28 The Network implemented interventions to reduce grievances.

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CIR.2.g #29 The Network collected and categorized inquiries, complaints, and grievances using SIMS, as directed by CMS.

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CIR.2.g #30 The Network supported the CMS Ombudsman, as requested.

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CIR.2.g #31 The Network utilized complaint and grievance data to plan new modular training initiatives, provide facilities with feedback, and/or make recommendations to CMS.

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CIR.2.g #32 The Network referred immediate and serious complaints or grievances to the applicable State Survey Agency or QIO and to the Project Officer within 24 hours of receipt.

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CIR.2. The Network reported all Task 2 activities in its Quarterly Progress/Status Report.

(Counted under Task 3.g.)

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Task 3. Administration

· The Network established a corporate structure that supports its operations and meets the statutory requirements.

· The Network established an organizational structure that addresses staff reporting lines as well as a committee structure that supports the efficient and effective accomplishment of the requirements of the current Statement of Work (SOW).

· The Network employed an adequate number of qualified administrative staff to manage the work of the contract and line staff to carry out the work.

· The Network established required boards and committees; specified appropriate roles and functions for these entities; promulgated policies, procedures, and bylaws to govern these entities consistent with industry best practices and with ESRD regulations; and appropriately documented meetings and actions for internal review and by/at the request of CMS.

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Task 3.a. Organizational Structure

A.3.a. #1 The Network has:

· Established a corporate infrastructure that supports its operations and meets statutory requirements;

· Established an organizational structure that addressed staff reporting lines and committee structure;

· Employed an adequate number of qualified administrative staff to manage the work of the contract and line staff to carry out the work; and

· Established required boards/ committees and policies, procedures, and bylaws to govern these entities.

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A.3.a # 2 The Network has a fully functioning Board of Directors including all of the following:

· Evidence of orientation to responsibilities as per Network policies, procedures, and bylaws;

· Responsibility for hiring the Executive Director (ED) and ongoing evaluation of the ED’s performance in meeting contract requirements;

· Responsibility for financial oversight and maintaining financial viability;

· Documentation of regular Board meetings showing evidence of Board oversight and actions;

· Documentation of Program oversight

· Composition of Board is representative of the Network’s service area and must include at least one patient.

· Must include one or more members from the PAC Committee

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A.3.a. #3 The Network established a Network Council that meets all of the statutory requirements of Section 1881(c) of the Act which does all of the following:

· Meets as necessary;

· Serves as a liaison between its provider membership and the Network;

· Includes renal providers and transplant facilities;

· Represents various geographic locations and types of professionals working for facilities in the area;

· Has at least one patient representative.

List number and dates of mtgs.

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A.3.a. #4 The Network has a fully functioning Medical Review Board, with the following disciplines, at a minimum:

- 1 patient representative;

- Representative from each associated discipline;

· Physician

· Nurse

· Social Worker

· Dietitian

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A.3.a #5 The Network Medical Review Board:

· Is actively engaged in ESRD treatment and members are qualified to evaluate the appropriateness of care delivered to ESRD patients;

· Meets the statutory requirements of Section 1881 (c) of the Act;

· Participates in the development and implementation of Network quality improvement activities;

· Includes at least one patient representative(s) and representative from each of the professional disciplines (that is, MD/DO, RN, RD and MSW)..

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A.3.a. #6 The Network has an active Patient Advisory Committee comprised of patients representing various regions of the service area, which did all of the following:

· Provided input into goals of the

· Network;

· Provided insights to the Network that were acted upon;

· Was represented on the Board of Directors.

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Task 3.b Network Staff

A.3.b #7 The Network’s staff structure met contract requirements for the:

· Executive Director/Project Director (appointed and evaluated on an ongoing basis by the BOD);

· QI Manager/QI Coordinator;

· Data Manager.

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A.3.b #8 The Network had the required professional and technical expertise, which included:

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· Patient Services Coordinator

· Community Outreach Coordinator;

· Registered Nurse with nephrology experience.

· Sufficient support staff to conduct, understand, and follow the activities/responsibilities described in the:

· ESRD Network Administration and Disaster Recovery Handbook;

· QualityNet ESRD Network Infrastructure Support Manual;

· QualityNet System Security Policies Handbook;

· QualityNet ESRD Networks BCCP and Template;

· Other supporting document provided by CMS.

A.3.b #9 The Network’s staff positions have been filled for most of the time, and any vacancies have been promptly filled or an active attempt is being made to fill the vacancy.

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Task 3.c Internal Quality Improvement Program (IQI)

A.3.c #10 Network has a written IQI Plan.

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A.3.c #11 The Network’s written IQI Plan includes the following activities at a minimum:

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· QI Projects;

· Evaluating and resolving complaints/grievances;

· Community education and resource activities;

· Collecting, analyzing, validating, tracking and reporting data;

· Performing administrative functions;

· Special Projects.

A.3.c #12 The Network has an internal reporting system for all IQI activities and ensures that reports are available for CMS monitoring.

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A.3.c #13 The Network’s IQI reporting system contains process measures that are sensitive enough to quickly detect problems in reaching targets.

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A.3.c #14 The Network submitted its IQI Plan to the PO for review 60 days after the beginning of the contract year and the plan was found to be acceptable by the PO.

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A.3.c #15 The Network IQI has built-in processes for rapid identification and correction of problems.

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A.3.c#16 The Network presented evidence in Quarterly and Annual Reports and in updated QIP Work Plan that activities, projects, measures, goals, and objectives were monitored and adjusted as needed.

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A.3.c. #17 The Network documented progress made on activities, projects, measures, goals, and objectives. The Network provided rationale(s) for why any activity, project, measure, goal, or objective was not met within the established timeframe.

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Task 3.d CMS Meetings

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· Required staff attended.

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· Required staff attended.

A.3.d. #20 The Network Staff, inclusive of the Executive Director, participated in additional conferences and meetings that support the overall mission of the national ESRD community as well as activities that support the Network’s strategic plans and advance its goals.

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Task 3.e Collaborative Activities with State Survey Agencies (SSAs) and Quality Improvement Organizations (QIOs)

A.3.e # 21 The Network has an ongoing relationship with the applicable CMS Regional Office(s) staff, including at a minimum the Regional Medical Director or the Division of Survey and Certification.

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A.3.e. #22 The Network assured that the Project Officer was aware of and participated in any discussion of issues/concerns with CMS Regional Office staff.

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A.3.e #23 The Network shared information to help SSA(s) carry out their legislated/regulatory responsibilities.

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A.3.e. #24 The Network shared information to assist QIO(s) in carrying out their legislative, regulatory, and/or contractual responsibilities.

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A.3.e #25 The Network assisted SSA or QIO(s) in investigation of quality of care issues, upon request and with CMS approval. May include:

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· Conducting reviews;

· Conducting cooperative activities with SSA/CMS to support sanctions or alternative sanctions;

· Providing technical assistance;

· Providing information regarding expected outcomes;

· Reporting patterns of complaints and grievances;

· Providing follow-up reports regarding complaints and grievances to referring agency;

· Reviewing follow-up reports from agencies that received Network referral of complaints and grievances.

A.3.e #26 The Network coordinated and collaborated with SSA and QIO(s) regarding QI interventions with providers.

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A.3.e. #27 The Network coordinated and collaborated with QIO(s) regarding QI projects aimed at facilitating provisions of CKD and ESRD care.

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Task 3.f Sanctions and Referrals

A.3.f #28 The Network has a written policy for sanction and alternative sanction recommendations and referrals that ensures all of the following:

· Recommending to CMS sanctions or alternative sanctions for facilities that consistently fail to comply with Network goals and/or are not providing appropriate medical care;

· Providing the necessary documentation, throughout the process, to support the recommendation and associated investigation;

· Tracking and trending of dialysis facility data in such a manner that alerts the Network to facility non-compliance;

· Referring to the QIO or State Office of Inspector General information collected while conducting contract activities that indicates that a physician may be failing to meet his/her obligations to provide quality care or is involved in Medicare fraud.

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A.3.f #29 The Network has the necessary documentation to support any actions associated with the activities under A.3.f #29.

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A.3.f.#30 The Network referred to QIO(s) or OIG physician information collected during contract activities that indicated a physician was failing to provide quality care.

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Task 3.g Required Administrative Reports/Activities

A.3.g #31 The Network submitted its Quarterly Reports: (Note: Each of the following elements must be met.)

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· On time (by the 15th working day after the beginning of each calendar quarter);

· One final hard copy and electronic copy delivered to the Project Officer;

· One final hard copy and electronic copy delivered to CMS Central Office after PO approval;

· Final electronic copy delivered to the Network Coordinating Center after PO approval.

A.3.g #32 The Network submitted its semiannual cost report and met all of the following: (Note: Each of the following elements must be met.)

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· On time (no later than the close of business on the 15th business day of the second calendar month following the closing date of the cost reporting period);

· Electronic copy delivered to the Project Officer and CMS Central Office.

A.3.g # 33 The Network submitted its Annual Report: (Note: Each of the following elements must be met.)

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· On time (by July 1 of each contract year);

· One hard copy delivered to the Project Officer;

· One hardcopy submitted to CMS Central Office and one electronic copy delivered to the ESRD Network Coordinating Center within 2 weeks of PO approval;

· Final Annual Report posted to the Network’s Web site within 90 days after PO approval.

A.3.g #34 The Network Annual report contains:

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· Description of activities conducted to meet ESRD Program goals;

· Assessment of activities and measurable achievement in meeting goals;

· Data on comparative performance of facilities and providers in identifying and placing suitable candidates in self-care and self-directed settings transplantation, vocational rehabilitation programs and other such programs to enhance quality of life;

· Identification of facilities that consistently failed to cooperate with Network goals;

· Recommendations for additional ESRD facilities in Network area.

A.3.g # 35 The Network submitted its Business Continuity and Contingency Plan and met all of the following: (Note: Each of the following elements must be met.)

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· On time (delivered on November 1);

· One final hard copy delivered to the Project Officer;

· One electronic copy on CD delivered to the CMS QualityNet Information Security Officer.

A.3. #36 The Network reported on all contract requirement (Tasks 1–4) activities in its Quarterly Progress and Status Report.

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Task 4 Information Management

· The Networks used an information system(s) designated by CMS to collect and maintain data pertaining to the ESRD Program and used the data to fulfill the Network’s contractual obligations.

· The Network did not develop software products for use with facilities or use by other Networks without written prior approval by CMS. Additionally, no money from this contract was used for data collection activities not specified in this contract unless pre-approved by the Project Officer and in accordance with other CMS directives.

· The Network referenced Chapter 4 of the Medicare ESRD Network Organizations Manual for additional information pertaining to data requirements in the SOW and the Network’s responsibilities for processing/maintaining the data.

· The Network met all responsibilities for information management and reporting within the CMS designated information system(s).

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Task 4.a System Capacity

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IM.4.a #2 The Network maintains equipment for secure transmission and communicating with ESRD facilities, CMS Central and Regional Offices, and stakeholders;

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IM.4.a #3 The Network used only CMS-approved statistical software for data analysis and profile analysis to facilitate disaster planning and other studies;

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IM.4.a #4 The Network established provisions for disaster recovery as outlined in the QualityNet Security documentation and submitted deliverables on time.

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Task 4.b. Database Management

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IM.4.b #6 The Network continually and promptly updated the databases with data received from providers/facilities.

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IM.4.b #7 The Network provided accurate data to CMS.

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IM.4.b #8 When requested, the Network reviewed and verified provider data including but not limited to:

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· Dialysis Facility Compare;

· Annual Facility Survey.

IM.4.b #9 The Network, through a change reporting process, researched, resolved, and made necessary corrections in the patient database to resolve discrepancies within 60 calendar days of notification.

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IM.4.b #10 The Network maintained an up-to-date facility database containing the mandatory data elements listed in the Medicare ESRD Network Organizations Manual.

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IM.4.b #11 The Network validated that the automated replication of the patient and provider data to the central repository was completed nightly.

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IM.4.b.#12 The Network, using an IQI process, developed, implemented, and consistently evaluated for effectiveness internal policies and procedures to ensure the timeliness and accuracy of all data entered into the CMS-designated information system.

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IM.4.b.#13 The Network performed data clean-up activities on a regular basis and other IT task as directed by CMS in support of a consolidated national database.

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IM.4.b #14 The Network developed and maintained policies and procedures to ensure timeliness and accuracy of all data entered into CMS-designated information systems.

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Task 4.c Collection, Completion, Validation, Submission, and Maintenance of CMS ESRD Forms

IM.4.c #15 The Network maintained accurate, complete, and current information for CMS-designated systems accounts.

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IM.4.c #16 The Network submitted facility survey data by the 5th working day of April.

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IM.4.c #17 The Network completed corrections to facility survey data by the third Friday in May.

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IM.4.c #19 The Network maintained a file of all hard copy CMS ESRD forms entered at the Network for at least 2 years.

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IM.4.c #20 The Network validated 3% of patient and physician signatures received electronically through VISION on CMS 2728 forms and reported results in the Annual Report.

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Task 4.d ESRD Forms Submission Compliance Rates

IM.4.d.#21 The Network tracked the receipt of CMS-2728 and CMS-2746 forms to ensure that the forms were submitted in a timely way, all mandatory data fields were completed, and the information in these fields was accurate.

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IM.4.d #22 The Network profiled all facilities to determine their compliance rates for submitting timely, complete, and accurate forms.

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IM.4.d #23 The Network maintained compliance rate information onsite and made it available at CMS’ request.

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IM4.d #24 The Network documented its notification of noncompliant/delinquent facilities with unacceptable semiannual and/or annual compliance rates.

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IM.4.d #25 The Network implemented and documented progressive strategies/interventions to help facilities improve their performance and reach national compliance levels.

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IM.4.d.#26 The Network evaluated progress and prepared and forwarded a sanction recommendation for those facilities that were not making reasonable attempts to improve performance.

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1. Semiannual—Reported in October

2. Annual—Reported in April)

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Task 4.e Kidney Transplant Data

IM.4.e #28 The Network:

· Received and processed kidney transplant data from providers and verified transfer of data from UNOS;

· Assisted UNOS in getting delinquent kidney transplant registration and follow-up information;

· Reported serious errors or discrepancies in UNOS data to CMS for follow-up with UNOS in 30 calendar days.

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Task 4.f Updating Status of Medicare ESRD Beneficiaries

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IM4.f #30 The Network utilized the standardized monthly National Patient Activity Report (NPAR) to collect patient event data from facilities.

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IM4.f #31The Network received changes to a patient’s status, as reflected by an event on the NPAR that was submitted by the facility on or before the 10th day of the following month.

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IM.4.f #32 The Network updated patient event data within 10 working days of receipt of change information.

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Task 4.g Coordination of Additional Renal-Related Information

IM. 4.g. #33 The Network processed CMS ESRD Forms on VHA dialysis patients from non-Medicare-approved VHA facilities.

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IM. 4.g #34 The Network responded to select inquiries from Network area from CMS provided/approved list of Medicare Advantage organizations regarding the status of CMS-2728s filed with the Network, and/or transplant status of ESRD Medicare beneficiaries.

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Task 4.h Development and Testing of ESRD Network Data and Data Systems

IM. 4.h #35 The Network participated in the following activities related to the successful development and implementation of a Web-based system to electronically collect and report ESRD administrative and clinical performance measure data:

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· Participated in the development of business requirements, data dictionary, and file specifications for ESRD data;

· Reviewed and provided comments on the ESRD Kidney Data Dictionary definitions, constraints, and valid values;

· Reviewed and provided comments on the ESRD business requirements and file specifications for the batch transmission of ESRD data;

· Participated in testing ESRD information systems, software products, tools, data information sets, business requirements, and file specifications.

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As Project Officer I recommend do not recommend that CMS continue this contract for the July 2010 – December 2010 Option Year.

Legend:

X scored elements that are to be counted in the grid. (Note: only the “Yes” answers are counted) used to quantify scored elements.

Italics instructions/guidance for the

PO

Shaded areas do not have to be scored.

Contract r eference information will appear only in the box es for scored elements.

Revised 01/07/10

Revised 01/20/10