Attachment J-9.docx

Attachment J.9 (Unofficial) ESRD NETWORK EVALUATION GUIDELINES

Contract Cycle 2010-2011

(In all areas, unless otherwise specified, the Regional Office Project Officer (PO) will determine compliance in conjunction with SO, CMS program staff, and other CMS representatives as appropriate.)

Task 1. NETWORK QUALITY IMPROVEMENT PROGRAM

The Network is to assist ESRD providers in assessing and improving the care provided to all individuals with ESRD. The Network shall accomplish this by establishing a Network Quality Improvement Program which includes:

Vascular Access Quality Improvement Project (FistulaFirst):

· Quality Improvement projects undertaken with dialysis providers and/or National Breakthrough Initiative coalition in the area of vascular access.

Clinical Performance Measures (CPMs):

· Collection, analysis, improvement, and monitoring of ESRD clinical performance measures (CPMs) in one or more of the established set of CPMs in the areas of adequacy of dialysis, anemia management, and vascular access (in the area of decreased rate of catheter use and monitoring for stenosis; increased fistula rate is not considered to be part of this requirement).

Network Specific Quality Improvement Projects:

· Network specific (QIPs) that advance the purpose and strategic goals of the ESRD Network Program, as resources permit, as specified in Task 1.c. QIPs can be undertaken in areas that are pre-approved as Agency areas of priority, or with prior approval from Project Officer, including QIPs undertaken with partners.

Facility Specific Quality Assessment and Improvement Projects (QAIPs):

· Assist ESRD providers and facilities (either individually or in groups) in the development and implementation of facility-specific, quality assessment and improvement actions to improve their patient care processes and outcomes.

The foundation of the Network Quality Improvement Program lies in the identification of sub-standard and sub-optimal care for individuals with ESRD and the development of targeted interventions to improve care.

As part of the Network’s role in conducting quality improvement activities, the Network should work to improve processes and outcomes of patient care by developing, implementing, and evaluating quality improvement projects in collaboration with Network Medical Review Board (MRB), Patient Advisory Committee, ESRD providers, and other partners.

The Network should be capable of moving from a methodically prescribed QIP/QAIP with significant CMS oversight to autonomous development of an effective facility-based rapid-cycle improvement initiative. A Network QIP/QAIP should include the following component parts:

· Program Description

· Program Goals and Objectives

· Identification of Key Partners

· Scope of Quality Improvement Program

· Program Structure, Including Data Requirements

· Identification of Program Resources (Personnel and Budget Allocation)

· Identification of Methodology for Program Evaluation

· Confidentiality Issues

· Conflict of Interest Issues

Task 1, Network Quality Improvement Program is broken down into four sub-tasks: 1a) Vascular Access Quality Improvement Project (FistulaFirst); 1b) Clinical Performance Measures (CPMs); 1c) Network Specific Quality Improvement Projects (QIPs); 1d) Facility Specific Quality Assessment and Improvement Projects (QAIPs); and 1e) Quality Improvement Work Plan (QIWP). A successful Network QI Program must actively pursue activities and engagement in all four of the sub-tasks under Quality Improvement (with subtask 1d, required as resources permit). All quality improvement activities (1a.-1d), are contained within a comprehensive Quality Improvement Work Plan (1e) that is developed in conjunction with the Network MRB. The status of the Quality Improvement Work Plan (and all components), is reported primarily as part of the Quarterly Report.

The Network shall implement quality improvement projects with dialysis providers in the area of vascular access as part of the Vascular Access Improvement Project (FistulaFirst). Performance for Task 1.a. will be based on improvements in Network-level rates of arteriovenous (AV) fistula use in prevalent patients. The CMS goal for the Medicare Program is that percentage of prevalent patients using AV fistula is at least 66% by June 30, 2011. Based on evolving science, historical growth, and potential changes to practice patterns, CMS reserves the right to change the methodology used to set Network-specific targets in subsequent contract years, as well as the actual area of measurement.

Networks shall collect aggregate vascular access data from 100% of their facilities (not including those excluded due to obvious justifiable reasons for exclusion, e.g., acute care hospitals, pediatric centers, facilities undergoing transition) using the FF data collection tool or other methods as provided by CMS. Facility data will be reported electronically to the CMS’s designated Information Technology Contractor(s) for those Large Dialysis Organizations (LDO) associated facilities where the LDO agrees to participate and is capable of submitting data timely, accurately, and in the proper format. Networks are responsible for knowing fistula use rated in LDO facilities and reporting to the Network regional PO if there is a concern with facility reporting electronically or not.

QI.1.a #1 Network Improvement Targets: Network Improvement in rates of AV fistula use in prevalent patients.

· Baseline

· Improvement required

· Network contract goal

· Network current rate (9/30/2010)

Networks will use the March 31, 2007 data to establish its baseline for the contract year. Each Network shall reduce its quality deficit by 20% during each contract year unless the number is less than the floor of 1 percentage point or greater than the ceiling of 4 percentage points, at which point the floor or ceiling would apply.

Evaluation of the contract specified minimum threshold performance level for fistula use in prevalent patients shall be based on the March 2008 Fistula First Dashboard data or other official CMS measurement system for vascular access data from 100% of Network facilities.

QI.1.a #2 Facility Reporting: Network collected vascular access data from 100% of their facilities (not counting those excluded) for tracking and monitoring AV Fistula rate.

Using the FistulaFirst data collection tool or other methods, as provided by CMS, Network must collect specified data elements from 100% of their facilities unless excluded. If Network believes that a facility is to be excluded from reporting requirement (in part of whole), justification must be documented and submitted to the PO for prior approval. Until such time if/when the PO exempts facility, Network will be required to obtain data.

For those facilities associated with Large Dialysis Organizations (LDOs) that agree to participate and are capable of submitting data timely, accurately, and in proper format, data will be submitted electronically directly to CMS’s designated Information Technology Contractor. Networks are still required to know the reporting rate for facilities associated with LDOs, and if/when there is a concern about the reporting rate Network must notify PO.

QI.1.a.#3-5 Facility Specific QIPs: Network undertook activities in support of the Vascular Access Improvement Initiative (FistulaFirst Breakthrough Initiative (FFBI)).

Network is responsible for employing those activities that address the needs of facilities in their specific Network. Large-scale departure from the approaches developed and adopted through national Breakthrough Initiative should be supported by documentation that supports the selection and use of that particular approach within the Network. These will be critical background elements should the Network not meet the fistula use target in the contract.

Furthermore, all Networks should have a strong measurement process in place to be able to monitor the progress of their projects. Timely Network-level interim measurements are critical for the assessment of the relationship between their work and the results they are observing both at the facility level, and critically, the Network level.

A Network process for reviewing/scanning the work/results ongoing in other Networks (e.g., through the Task 1.A section of the Network Quarterly reports and the CMS FF Dashboard Grid) is critical for timely consideration of successful/unsuccessful strategies/tactics employed elsewhere. This scanning is designed to allow the ESRD Network to find and explore approaches that can be exploited nationally to improve fistula rates on a large scale in a timely fashion.

QI.1.a#6-7 Educational/Technical Assistance: The Network undertook educational activities that advance the goals of the Vascular Access Quality Improvement Project (FistulaFirst) and assure achievement of Network measurement targets in the area of vascular access.

Network shall (as part of collaborative project with dialysis providers) undertake educational activities, and provide technical assistance to enhance the facility’s fistula placement, patency, and functionality rate; including providing facilities with training materials on: cannulation, AVF maintenance, and monitoring.

QI.1.a#8 Participation in National Breakthrough Initiative: The Network participated in the Fistula First Breakthrough Initiative coalition meetings and actively engaged in activities with at least one subgroup.

Engagement will be considered to be active if Network activities include, as example:

· Leading and activity;

· Implementing an activity;

· Measuring results of an activity;

· Providing supporting data for an activity; and/or

· Working collaboratively on a joint project with another participant in the Breakthrough Coalition such as a Quality Improvement Organization (QIO).

QI.1.a#9 Network Collaborations: The Network worked with their partners to:

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

· Achieve ESRD treatment changes at a system level.

In working with partners, the Network (and partners) shall promote the utilization of tools already available, through Network, Network Coordinating Center, the Breakthrough Initiative, other partners, etc., and only undertake development of additional tools, materials, etc. (in accordance to CMS procedure) when there is a clear gap in availability of such items. Additionally, Networks shall work with partners to “spread” quality improvement programs and activities already demonstrated to be effective, whenever possible/appropriate.

· Activities with partners (e.g., QIOs) should be undertaken to create change at a system level in areas where Network alone cannot impact (or impact as effectively as with partners) such as hospital adoption of standards of care that promote the use of AV fistulas such as vessel preservation, evaluation, mapping, and discharge planning.

Task 1.b. Clinical Performance Measures (CPMs) Project (QI.1.b #1-5) SOW C.3.B.1, ESRD Manual Chapter 5

CPM is an indicator to estimate or monitor the extent to which the actions of a health care practitioner or provider conform to practice guidelines, medical review criteria, or standards of quality. The primary use of the CPMs for the Network Program is to facilitate quality improvement among dialysis providers.

To support the CPM project, annually, the Network shall collect data on specific ESRD CPMs as described in the ESRD Network Organizations Manual instructions in Chapter 5. The purpose of collecting data e CPMs are to:

· Described/analyzed the practice patterns, processes, and outcomes of care for the targeted patient population.

· Describes/analyzed conformance to clinical practice guidelines.

· Provided the facilities/providers with information to stimulate data improvement in patient care, practice patterns, processes, and outcomes for the targeted patient population.

QI.1.b. #1 Clinical Performance Measures Reporting: The Network completed all required steps (in accordance to established procedure and timeframe) including: collection of CPM data forms from its dialysis facilities; data entry; data validation; timely data submission; and distribution of results.

Chapter 5 of the Medicare ESRD Network Organization Manual describes the project, target population, sampling methodology, instructions for the data collection, validation procedures of the CPMs, and the distribution requirements for the ESRD CPM Annual Report, and guidance for establishing target performance levels for selected CPM indicators.

PO will look at all required areas (e.g., collection of CPM data forms from its dialysis facilities; data entry; data validation; timely data submission; and distribution of results) through reports supplied by CMS Information Technology Contractor, reports from Network, and other information to determine if each step was conducted according to established procedure and timeframe. Success is determined by a “Yes” response in all required steps.

QI.1.b #2-5 Clinical Performance Measure(s): Networks, in conjunction with their MRB, shall develop and conduct QIPs based on one or more of the established set of ESRD CPMs for adequacy of dialysis, anemia management, vascular access (in the defined areas not to include for the purpose of this requirement, increase rate of fistulas), or other CPMs developed or adopted by CMS.

Since the primary use of CPM measures by the Networks is to encourage and facilitate quality improvement among dialysis providers, CMS is providing, as a guide, target clinical performance outcome measures to assist Networks in evaluating where to concentrate or prioritize their efforts. The CPMs are high-priority topic-specific targets to help guide Networks and their MRB as they proactively plan QI activities or prioritize responses to apparent quality issues. All Networks should be addressing some or all (depending on need in Network area) of the following CPMs over their 3-year contract through a combination of QI activities set forth in the CPMs section of the contract and the annual QIPs:

· Adequacy of Dialysis (in-center hemodialysis patients) – attain/maintain 80% of patients with URR > 65% or 84% of patients with Kt/v > 1.2. (See SOW C.3.B.1, and ESRD Manual Chapter 5)

· Anemia Management - attain/maintain 70 % of patients to have a mean hemoglobin of > 11 gm/dL (See SOW C.2.C, C.2.D, ESRD Manual Chapter 5 and Exhibit 5-1)

· Vascular Access - Decrease catheter use - less than 10% of prevalent hemodialysis patients over 18 years of age should be maintained on catheters for 90 days or longer; (See SOW C.3.B.1, and ESRD Manual Chapter 5)

· Vascular Access - Increase use of fistulas - more than 40% of prevalent hemodialysis patients over 18 years of age should have an AV fistula; (See SOW C.3.B.1, and ESRD Manual Chapter 5)

· Vascular Access - Monitoring for stenosis - monitoring AV grafts for stenosis should occur for 100% hemodialysis patients. (See SOW C.3.B.1, ESRD Manual Chapter 5 and Exhibit 5-1)

Project officers will annually review the status of CPMs, by Network, to familiarize themselves with topics that the Networks should consider for quality improvement activities. Networks and ROs should meet and discuss the CPMs and the Networks' plans to address these CPMs in the current year. The Network’s plan for addressing CPMs (communicated in separate document and/or in the Quality Improvement Work Plan) should have been approved by the RO (the PO should have an email or letter confirming its approval).

In submitting information for approval, the Network shall include information on:

· The Network's level of performance and trend compared to the goal according to the most recent CPM measures.

· The Network’s brief delineation of its process for prioritizing its efforts. This should include, at a minimum, discussions with its MRB (and other appropriate committees such as Network Council and Patient Advisory Committee) and PO.

· The Network’s specific activities planned for each CPM topic and the rationale behind those decisions.

The evaluation (Y/N) of the CPM component of the Quality Improvement Program would be based on the degree of adherence to the Network’s work plan for conducting the CPM component. In reviewing the area, the PO will be looking for:

· A description/analysis of the practice patterns, processes and outcomes of care for the targeted patient population;

· A description/analysis of conformance to clinical practice guidelines; and

· Evidence of information that was provided to facilities/providers to stimulate data improvement in patient care, practice patterns, processes, and outcomes for the targeted patient population.

Network shall work with MRB and other partners, as appropriate, and as resources permit, to undertake 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 for quality improvement within the Network area. In doing so, Networks can undertake activities in areas that are pre-approved as Agency area of priority, or with prior approval from the PO, including QIPs undertaken with partners.

QI.1.c. #1 Selection of QIPs: Network developed QIPs by actively working with MRB (and Network Council and Patient Advisory Committee as appropriate) and other partners, and selected areas 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 for quality improvement within the Network area.

PO will be looking to determine if QIPs were selected and developed by working actively with: (1) MRB and (2) and at least one of the following (when determined appropriate, which would be expected to be in most circumstances):

· Patient Advisory Committee;

· QIO;

· Providers;

· Affiliations and Associations;

· Beneficiary Groups; or

· Other Appropriate Members of the Renal Community.

In addition to determine who (m) the Network worked with, the PO/SO considers if it was “active” involvement. In doing so, they consider such activities as the Network working with partner to identify an opportunity for improvement from additional information available to it, such as the CDC surveillance information and center specific reports, and whether the Network acted upon this information.

Further, PO will determine if QIPs selected are either in the pre-approved area outlined in Task 1.c. or that the Network obtained prior approval (from PO) for selected area. The PO will also determine compliance in the area of QIP selection by asking such questions as:

· How does the Network identify opportunities to improve quality of care (other than CPM)? The key to this question is the word “actively”. (Passive identification of opportunities is not sufficient.)

· What areas have been identified in this contract year?

· What activities has the Network undertaken to address them?

QI.1.c.#2-4 Conducting QIPs: The Network QIP will include quantitative targets and methods for rapid cycle evaluation and activity adjustments, and data must be obtained in accordance to established procedure.

Documentation on QIP should include the following details:

· Project Name

· Baseline measurement

· Re-measurement criteria and status

· Analysis of sustainability

Performance will primarily be based on following the QIP plan, and will be monitor through the Network Specific Quality Improvement Project component of the Quality Improvement Workplan, as reported through the Quarterly Reports. Project officers will take into consideration the level of effort Networks that is devoted to other pressing quality improvement areas, as indicated in the Quarterly Reports, when evaluating activities. As in all areas of the Quarterly Report, PO will be looking at other supporting information to assess if reported activities did occur, in accordance with work plan. Supporting information includes agenda and/or presentations for annual meeting and other meetings, newsletters (patient and/or facility), and other material.

Additionally, PO will be looking to determine if data used for conducting the QIP plan was obtained according to procedure, including obtainment of prior approval of PO when data elements are not otherwise supplied or available.

Task 1.d. Facility-Specific Quality Assessment and Improvement Project (QI.1.d. #1-5) (See SOW C.3.B.1, and ESRD Manual Chapters 2 and 5)

The Network shall have and maintain the capacity to respond to local needs upon request by facilities or when poor performance/problems are identified in conjunction with the responsibilities set forth in section C.3.B.

QI.1.d. #1-5 The Network facilitates facility specific quality improvement activities that may include:

· Fostering internal QI at the facility level;

· Providing QI/technical assistance;

· Providing education; and/or

· Promoting and assisting facilities to conduct focused local QI initiatives.

One of the greatest values of the ESRD Network Program is being able to affect quality improvement at the facility level. Opportunities for facility assessment and improvement can be identified by working in collaboration with CMS, the QIOs, State survey agencies, ESRD providers/facilities, Medicare Advantage Organizations, ESRD facility owners/managers, national and/or local renal related professional organizations, LDOs, patient organizations, other ESRD Networks, and the Network MRB and other committees (e.g. Patient Advisory Committee and Network Council). The objectives of these QI activities are to assist in the facility level development, maintenance, and evaluation of an effective data driven, interdisciplinary QAIP program.

The PO will determine compliance in this area in conjunction with SO. Success is determined by Network successful documentation that they have: fostered internal QI at the facility level; provided QI/technical assistance; provided education; and/or promoted and assisting facilities to conduct focused local QI initiatives.

Quality Improvement Work Plan: No later than 60 calendar days after the beginning of the contract cycle, the Network will submit their initial Quality Improvement Work Plan for the contract year, developed in conjunction with the Network MRB, to the regional Project Officer. The Work Plan must be reviewed, evaluated, and modified, as appropriate, in conjunction with the MRB within 60 working days of receipt of CPM clinical data, unless directed otherwise by CMS, The Work Plan is considered a living document and is used by the Network, MRB, and the Project/Science Officer to quickly see what activities/projects are planned and how the activities/projects are progressing.

The Quality Improvement Work Plan is a tool that when properly executed will give a Network, MRB, and the regional Project Officer a systematic way of looking at and improving or assessing Network processes rapidly. It is a document that can stand alone, but is also incorporated into the Network’s Internal Quality Improvement processes.

QI.1.e. #1-3 Initial Quality Improvement Work Plan: Network submitted the initial Quality Improvement Work Plan no later than 60 calendar days after the beginning of the contract year.

In evaluating this area, the PO will be looking to determine if the Quality Improvement Plan:

· Addressed plans for achievement of all elements, including measurement and re-measurement criteria for each activity;

· Was designed from available data sources in such a way as to allow rapid cycle improvement; and,

· Used a process for rapid evaluation and adjustments.

QI.1.e. #4 Final Quality Improvement Work Plan: Annually, no later than 60 working days after receipt of CPM clinical data, each Network shall revise their written QI plan that prioritizes, plans, and designs improvement activities. These QI projects shall include quantitative targets.

In evaluating successful completion of this area, the PO/SO will look at whether:

· The plan was submitted timely. (No later than 60 days after receipt of CPM clinical data)

· Progress on the plan was noted in the quarterly report. (This includes revisions to the written QI Work Plan)

· Documentation is sufficient to support that the Network implemented activities in accordance with its workplan for the CPM, and Network Specific and facility specific QI activities, including the current target levels.

QI.1.#1 Reporting Exception(s): Network submitted any completed quality improvement project to the Project Officer within 30 calendar days upon completion.

PO will determine that timeframe has been met, and that adequate information was supplied. Note: Although this does not appear as a scored element of Task 1; it should be assessed to determine a Network’s ability to follow a project through to completion as it is a requirement in the SOW and is referenced in the manual as a requirement.

QI.1.#2 Status Reporting: Network reports all Task 1 activities in their Quarterly Progress/Status Report within 15 days after the beginning of the calendar quarter.

PO will determine that timeframe has been met, and that adequate information, on all areas, was supplied.

Task 2. COMMUNITY INFORMATION AND RESOURCES (CIR.2. #1-28)

The Network is to assist providers and patients in its area to improve the quality of care and the quality of life of ESRD patients by providing informational material and technical assistance on ESRD related issues. In carrying out the activities under this task, the Network shall perform at least the following functions:

· Implement and/or maintain a procedure for receiving, evaluating, resolving and tracking patient grievances and complaints (including implementing educational programs to assist facility staff in handling difficult situations);

· Establish and/or maintain a national userfriendly, toll-free number to facilitate communications with patients within the network area;

· Develop and/or maintain a Network web site that follows CMS standards and guidelines; and

· Comply with laws that prohibit excluding or denying individuals with disabilities an opportunity to receive the same information and assistance provided to other patients without disabilities.

Task 2, Community, Information, and Resources (CIR) is broken down into seven sub-tasks; 2a) Provision of Educational Information-New Patients, 2b) Provision of Educational Information-Patients, 2c) Provision of Educational Information – Providers/Facilities, 2d) Provision of Technical Assistance, 2e) Emergency/Disaster Preparedness and Response, 2f) Coalition, and 2g) Complaints and Grievances. A successful Network CIR Program must actively pursue activities and engagement in all seven of the sub-tasks. In carrying the functions, the Network must methodically collect data to assess the effectiveness of its activities under CIR. This is an ongoing rapid-cycle assessment that identifies targeted areas for the provision of educational information, technical assistance, and the resolution of difficult situations, complaints, and grievances. The Network reported the status of its CIR Program activities in the Quarterly Progress and Status Report referenced in section C.3.D — Task 3.g of the Statement of Work (SOW). If more resources than allocated are needed to conduct these activities, the Network contacted its PO for guidance in prioritizing work activities.

CIR.2.a.#1-2 Network Introductory Letter: The Network provided the Network letter, on Network letter head, containing all required elements, to the appropriate CMS contractor for distribution in the New ESRD Patient Orientation Package (NEPOP).

In evaluating this requirement, the PO will determine if the letter was provided according to the established timeframe and if it contained all of the required elements such as:

· Information of the Network’s grievance procedure;

· Network specific information, including:

· Network organization’s toll-free number;

· Services and assistance offered;

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

· Patient care;

· Treatment options; and,

· Services.

· Information about the function of the SA to include address and phone numbers of each SA in the Network contract area, and the fact that the SA receives and investigates complaints and grievances.

CIR.2.a. #3 NEPOP Follow-Up: Network organization followed-up on all returned mail for the NCC when NEPOP are undeliverable.

For evaluation, the PO will assess if the Network:

· Determine whether patient is deceased or is still alive and has a current address;

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

· Update its patient database in CMS’ designated Information System; and,

· Report Monthly to the NCC the number of returns due to death and address changes.

CIR.2.b. #4-5,7Available Information: The Network makes available, at a minimum, the following informational materials to its patients in its network area, and annually informs its patients on how to contact the Network to obtain the information. The methods used must have the potential to reach all beneficiaries.

PO will determine if the information was made available, and provided upon request included all of the following:

· The role of the ESRD Network;

· Network process for receiving, reporting, resolving, and tracking patient complaints and grievances:

· Treatment options and new ESRD technologies available for patients;

· Educate and encourage patient use of those treatment settings most compatible with obtainment of the maximum rehabilitation achievable and participation in activities that will lead to the best possible quality of life;

· Vascular access information;

· State/regional vocational rehabilitation programs available in the Network area;

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

· Website, which is 508 compliant, contains the Network grievance process, location of the Network, toll-free number for patients, current completed Annual report, Network Goals, and a link to Medicare.gov/DFC; and

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

· Information on Patient Advisory Committee and how to join;

· Information on the importance of immunizations; and

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

At least annually, the Network informs its patients on how to contact the Network to obtain the information. As example, the Network may use any of the following approaches to reach individuals with ESRD:

· Posters in facilities;

· Newsletters;

· Videos;

· Workshops;

· Mailings of the new patient packages to beneficiaries.

The activities and strategies for educating and encouraging patients should be evident in the Network-wide Internal Quality Control Plan and reported in the Network’s overall Quality Improvement Work Plan. Information relevant to the need for activities and strategies can be found in the SIMS data and in other reports generated by the Network. The PO/SO will utilize this information and inquiry to assess the Network’s success in recognizing a need for education and encouragement and implementing strategies and activities to meet this need.

The PO will determine compliance. Success is determined by a “Yes” response to all of the above. Additionally, the PO will verify that the Network utilized the Patient Advisory Committee, where applicable in fulfilling this requirement.

CIR.2.b. #6 Efficiency and Effectiveness: In fulfilling this requirement, the Network shall utilize information that is already available, and distribute information through the most effective an efficient approaches possible.

PO will determine if, and to what extent, the Network utilized information that was already available through CMS, CMS contractors (e.g., other Networks, the National Coordinating Center, QIOs), other federal agencies, renal partners (e.g., beneficiary representative groups, provider organizations and corporations), and other sources as appropriate. It is expected that at a minimum, before Network expends resources to create knew material, the feasibility of using information from such sources would have been explored.

In determining distribution methods for getting the material to individuals, the PO will consider the extent to which a Network partnered with others, or utilized the opportunities presented through partnership (e.g., training events, meetings, newsletters). Where it is more efficient and effective to do so, Network can subcontract with appropriate renal partners to fulfill some or all of these patient information requirements.

Task 2.c. Provision of Educational Information – Provider/Facilities (CIR.2.c #8-10) SOW C.3.B.1, ESRD Manual Chapter 6

The Network reports on the provision of educational information activities in its Quarterly Report.

CIR.2.c. #8 Distribution of Information: The Network distributes, at a minimum, the following new or revised informational materials to the providers/facilities in its network area with a directive to make the information available to its patients on how to contact the appropriate Network organization to obtain the information.

This includes all of the following:

· NW Annual Report, which contains NW goals, activities, and plans;

· Regional and national patterns/profiles of care;

· QIP project results;

· Information on the importance of immunizations;

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

· How to access and use Medicare’s DFC Report; and

· Information on the availability of VISION and other systems developed by CMS.

The PO will determine compliance. Success is determined by a “Yes” response to all of the above. Additionally, the PO will determine if the Network utilized the Patient Advisory Committee, where applicable in fulfilling this requirement.

CIR.2.c #9 Specific Activities: In addition, the Network is required to conduct specific activities.

The PO will determine if the Network completed the following activities in accordance with any applicable timeframe and procedures:

· Conduct special mailings;

· Annual printing and distribution of Dialysis Unit Specific Reports;

· Educate and encourage patient use of those treatment settings most compatible with obtainment of the maximum rehabilitation achievable and participating in activities that will lead to the best possible quality of life;

· Educate and encourage patients regarding use of modalities that will lead to maximum independence and highest quality of life;

· Distribution of information regarding Federal Drug Administration alerts, recalls, etc.; and

· Provide updated information to providers/facilities in its Network area with a directive that each provider/facility makes the information available to its patients or inform its patients on how to contact the Network to obtain the information.

Success is determined by a “Yes” response to all of the above. The PO will determine compliance.

CIR.2.c #10 Efficiency and Effectiveness: In fulfilling this requirement, the Network shall utilize information that is already available, and distribute information through the most effective an efficient approaches possible.

PO will determine if, and to what extent, the Network utilized information that was already available through CMS, CMS contractors (e.g., other Networks, the National Coordinating Center, QIOs), other federal agencies, renal partners (e.g., beneficiary representative groups, provider organizations and corporations), and other sources as appropriate. It is expected that at a minimum, before Network expends resources to create knew material, the feasibility of using information from such sources would have been explored.

In determining distribution methods for getting the material to individuals, the PO will consider the extent to which a Network partnered with others, or utilized the opportunities presented through partnership (e.g., training events, meetings, newsletters).

Task 2.d. Provision of Technical Assistance (CIR.2.d #11-12) SOW C.3.B.1, ESRD Manual Chapter 6

The Network reports on the provision of educational information activities in its Quarterly Report. (See SOW C.3.D. – Task 3.g. and ESRD Manual Chapter 2)

CIR.2.d. #11 Technical Assistance will be provided upon request of provider or patient.

PO will determine if, at a minimum, when requested, the Network has done or is able to do all the following:

· Identifies available providers and/or facilities to patients (including transient patients) seeking ESRD services;

· Refers those patients to the Medicare.gov Dialysis Facility Compare (DFC) web site;

· Assist individuals with ESRD in understanding the information provided on the DFC;

· Educates dialysis facility professional staff regarding the use of information on DFC;

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

· Provide patient education regarding kidney transplantation, home therapies, including in-center self care;

· Provide patient education regarding immunizations;

· Assists providers/facilities to do timely patient assessments thus promoting appropriate and timely referrals for kidney transplant;

· Address impediments to referrals and/or transplantation;

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

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

· Assist providers/facilities in developing appropriate quality improvement plans if they are having difficulty in meeting Network goals, Medicare certification requirements, or P4P program objectives or other such requirements;

· Assists facilities in developing plans for local disasters;

· Assist providers/facilities in development of mechanisms for assessing the health-related quality of life of patients; and,

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

The PO will determine compliance. Success is determined by a “Yes” response to each of the above.

CIR 2.d. #12 The Network annually informs facilities/providers and patients that it is available to provide technical assistance upon request.

PO will determine if the Network completed task through Network documentation (and verification where appropriate). Documentation must include sufficient detail on procedures employed, and methods utilized to determine that facilities/providers received notification.

Networks shall be required to facilitate and assist providers/facilities in developing plans for local disasters.

CIR 2.e.#13-14 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 & 16.

· PO will determine compliance. Consider/ask about partnership relationship and review the written back-up agreement.

CIR 2.e.#14-16 The Network is required to:

· Facilitate and assist providers/facilities in developing, implementing, and executing plans for local disasters;

· In the event of a local disaster, assist patients in identifying dialysis facilities that can provide ESRD services and track availability of services;

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

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

· Assist facilities with emergency planning;

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

· As directed and/or permitted by CMS, 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/regional calls with providers, emergency workers, and other essential persons; and,

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

As appropriate, the Network will report these activities in the Quarterly Progress and Status Report referenced in Section C.3.D – Task 3.g. PO will evaluate successful completion by affirmation that requirements have been met (as appropriate), as demonstrated through documentation.

Task 2.f. Coalition (CIR.2.f #17-18) SOW C.3.B.1

The Strategic Partnership for Change (SPC) is an initiative to support strategic partnerships and coalitions among the renal community through national and local training, and on-going consultant to support. The Network shall participate in, and actively engage in, all associated activities.

In addition, the Network will be responsible for assembling and/or sustaining an active coalition that conducts activities that supports achievement of the ESRD Network program goals, mission of the HCQIP, and/or Network QI activities. Network shall submit any changes to the coalition focus to their PO for prior approval and must work with any CMS specified contractors to assist in meeting these requirements.

It is expected that by virtue of the Networks participation in training activities, and through practical experience, the Network shall be able to:

· Build partnerships with new entities;

· Expand and enhance existing partnerships;

· Create greater ownership by partners in coalition;

· Utilize other available resources by having coalition partners bring resources to the table or identify others with resources; and,

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

CIR 2.f. #17-18The Network has assembled and/or sustained an active coalition that conducts activities that supports achievement of the ESRD Network program strategic goals, mission of HCQIP, and/or Network QI activities.

The Network has met the following requirements:

· Convened a coalition of key partners;

· Convened a coalition with an established vision, mission, goal(s), and operating procedures jointly agreed to by coalition members;

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

· Identified and recruited key partners and engaged in active participation in coalition activities;

· Expanded available resources by having partners bring resources to the table and/or identify others with resources;

· Ensured resources outside of the Networks will be used to achieve coalition goals; and

· Engaged in collaboration problem solving of jointly shared problems, resulting in innovated solutions that lead to problem solving actions.

The Network is responsible for recording activities, accomplishments, and challenges in the Quarterly Progress and Status Report referenced in Section C.3.D. – Task 3.g. PO will evaluate successful completion by affirmation that requirements have been met (as appropriate), as demonstrated through documentation.

The Network shall assume a proactive role in the prevention, facilitation, and resolution of complaints and grievances, including implementing educational programs that will assist facility staff in handling difficult situations, where appropriate. The Network shall also conduct trend analysis of reported situations to detect regional, local, or facility specific patterns of greater concern. Each Network shall be responsible for, but is not limited to, the following activities:

· Provide dialysis facilities with resources and educational programs under the Decreasing Dialysis Patient Provider Conflict Initiative designed to provide facility staff with an understanding of the issues and skills to prevent, intervene, or mitigate difficult patient and/or facility situations;

· Upon request, assist in the resolution of patient, provider, and/or facility complaints and grievances, by providing education, and/or facilitating solutions, and/or making referrals, which address the issue(s) involved;

· Describe and report in the Quarterly Progress and Status Report, and upon CMS request, patient and facility complaints/grievances and Network actions and interventions in an aggregate and narrative format, unless otherwise specified by CMS;

· At a minimum, annually, analyze facilityspecific data to identify patterns of concern at the facility or Network level, and opportunities to improve;

· Implement interventions aimed at reducing grievances and/or the numbers of difficult situations;

· Collect and categorize, as directed by CMS, inquiries/complaints/grievance data using SIMS, or other mechanism specified by CMS;

· Work with and implement activities to support the CMS Ombudsman, as directed by CMS; and;

· Utilize grievance data to plan new modular training initiatives, provide facilities with feedback, and/or make recommendations to CMS.

CIR.2.g. #19 The Network (proactively) assisted in the resolution of patient, provider, and/or facility complaints and grievances.

The Network followed the CMS national policy in the ESRD Network Organizations Manual instructions Chapter 7, for evaluating, resolving, and reporting patient grievances, complaints, and facility concerns. Within 24 hours of receipt, the Network referred immediate and serious grievances to the appropriate CMS regional office and State survey agency. On request from CMS, the Network assisted the State survey agency with the investigation of a complaint or grievance.

The PO will determine if the Network addresses the complaints through one or more of the following (as appropriate):

· Investigating;

· Educating;

· Facilitating; and/or

· Referring. (See SOW C.3.C.1, and ESRD Manual Chapter 7)

Further, the PO will determine if the Network followed the procedures as outlined in the ESRD Network Organizations Manual in assisting patients and/or facilities with complaints and grievances. (See SOW C.3.C.1, and ESRD Manual Chapters 6 and 7) The PO will determine compliance through documentation and by pulling a sample of cases for review.

CIR.2.g. #20 The Network conducted trend analysis of reported situations.

Trend analysis of data is utilized to identify patterns of concern at the facility and Network level.

Evaluation will be conducted to determine if the Network conducted trend analysis to identify opportunities for improvement at the facility and Network level and to implement a plan to address and improve the patterns/areas of concern. The PO will determine compliance using discussion, documentation on analysis, and samples where appropriate.

CIR.2.g. #21 The Network provided dialysis facilities with resources and educational programs under the Decreasing Dialysis Patient-Provider Conflict Initiative.

Evaluation will be to determine through documentation Network provided the PO with information concerning how many packets have been provided to dialysis facilities, any training provided to facilities, and any feedback from evaluations, or improvement in trend analysis.

CIR.2.g. #22 The Network described and reported in the Quarterly Report patient and facility complaints/grievances, and Network actions and interventions.

Unless otherwise specified by CMS, Network shall report in the Quarterly Progress and Status Report aggregate, quantitative information on type and quality of complaints and grievances, average time period for handling complaints and grievances, and mode for handling from beginning to end of Network involvement. Additionally, the report should include, in narrative format, information on the nature of complaints and grievances, and actions taken to resolve complaints and Grievances.

The PO will determine compliance through review of the Quarterly Progress and Status Report.

CIR.2.g. #23 Quarterly, at a minimum, the Network analyzed facility-specific data to identify patterns of concern.

The PO will determine compliance through review of the Quarterly Progress and Status Report.

CIR.2.g. #24 The Network implemented interventions to reduce grievances.

The Network promotes a relationship with facilities, providers, beneficiaries, etc. on its beneficiary complaint process. This may include one or more of the following:

· Training programs;

· Annual-meeting sessions;

· Resolution of individual grievance cases; and

· Other (list in comments) (See SOW C.3.C.1, and ESRD Manual Chapter 6)

The PO will determine compliance through discussion and documentation. Success is determined by a “Yes” response to any of the above.

CIR.2.g. #25 The Network collected and categorized inquiries, complaints, and grievances using SIMS and as directed by CMS.

The PO will be looking for documentation that the Network keeps an accurate record of the type, nature, outcome of and time required for its grievance, complaint. PO may utilize information provided by CMS, and/or CMS IT contractor, in making determination.

CIR.2.g. #26 The Network supported the CMS Ombudsman as requested.

Requests for assistance by the Ombudsman will first go to the PO from CO; therefore the PO will have information to support the assessment of this sub-task. Vise versa, requests for assistance from the Network to the Ombudsman will go from the Network to the regional PO.

The PO will determine compliance through discussion and review of activities in its Quarterly Progress and Status Report referenced in section C.