J-4_Reporting_Requirements.docx

Attachment J-4 Reporting Requirements

Table of Contents

I. Introduction

To ensure consistent reporting across the Networks, CMS has created standardized reporting templates for Network use. This Attachment provides templates and additional guidance for completing specific reporting requirements in the Statement of Work (SOW) and Statement of Deliverables (SOD), including requirements for reporting to the ESRD Network Coordinating Center (NCC). The Network shall report to CMS as specified in the SOW and Statement of Deliverables (SOD).

II. Network Monthly Progress and Status Report

Network Monthly Progress and Status Reports keep the Contracting Officer’s Representative (COR) and Government Task Leaders (GTLs) updated on the Network’s activities, enable the COR to quickly assess the Network’s progress, and allow the Network to describe challenges that require the COR’s support and guidance.

The Network shall use the CMS-approved template (Exhibit J-4-1) in reporting monthly to the COR and GTL.

In its Network Monthly Program and Status Reports submitted to the COR and GTL, the Network shall:

· Summarize issues in fulfilling contract requirements, including barriers related to quality improvement activities and other activities

· Provide data and analysis as required by CMS, including data elements as required by the SOW

· Alert the COR to potential quality of care issues and other concerns about provider performance

· Describe collaborations with Quality Improvement Organizations (QIOs), State Survey Agencies (SAs), Hospital Engagement Networks (HENs), and renal stakeholders.

The information to be provided in the Network Monthly Progress and Status Report includes, but is not limited to:

· Description/evaluation of Educational activities

· Description of emergency preparedness/disaster activities

· Reporting of Security incidents and NEPOP statistics

· Summary of Patient Engagement found during network facility visits

· Summary and statistics related to grievances activities/Access to Care

· Summary of activities for related to Grievance/ICH CAPHS/ LTC/ HAI BSI & Vaccinations/AIM2/QIP and Data Quality QIAs

· Details of Network involvement with QIO(s), HENs, and other stakeholders

· CROWNWeb deliverable updates

See Exhibit J-4-1 for the Network Monthly Progress and Status Report template.

III. Semi-Annual Cost Report

The Network shall submit a semi-annual report of Network operating costs to the COR and to the CMS ESRD Network Reports electronic mailbox (esrdnwreports@cms.hhs.gov), using the CMS-approved template and accompanying instructions. Cost information shall reflect actual costs incurred for the period. The Network’s financial records and general ledgers shall support cost information.

The cost report includes the following categories (see CROWN Memo 13-0705-CO for more information):

· Transition Costs

· General Requirements

· Patient and Family Engagement

· Evaluate and Resolve Grievances

· Promote Use of ICH-CAHPs

· Address Issues Identified through Data Analysis

· Patient Appropriate Access to In-Center Dialysis Care

· Vascular Access Management

· Patient Safety: HAIs

· Population Health Innovation Projects

· Support for ESRD Quality Incentive Program (QIP) and Performance on QIP Measures

· Support for Facility Data Submission to CROWNWeb and the National Healthcare Safety Network (NHSN).

See Exhibit J-4-2 for the Semi-Annual Cost Report template.

IV. Annual Report

The Network shall prepare an Annual Report for each calendar year, using the CMS-approved template.

The Annual Report reaches a broader external audience than other reports the Networks compile. Because the Network will make this report available to stakeholders and members of the public, the Network shall ensure it is comprehensive and understandable to those not affiliated with the ESRD Network Program.

Consistent with Exhibit J-4-3, the Annual Report template, the Network shall include the following information in the Annual Report:

· A statement of Network goals

· Data on Network performance in meeting goals (including data on facilities’ comparative performance in identifying and placing patients in appropriate settings for self-care, transplantation, and vocational rehabilitation programs)

· An analysis of Network activities conducted under each AIM, Domain, and Sub-Domain of the SOW during the calendar year. The analysis shall include outcomes with respect to the quality and safety of ESRD care, whether activities met Network and CMS goals, and a summary of activities’ impact on the ESRD population, including the comparative performance of facilities in placing patients in appropriate settings for self-care, transplantation, and vocational rehabilitation programs;

· Identification of those facilities, providers, and practitioners that failed to provide appropriate medical care, cooperate with Network goals, and/or follow the recommendations of the Medical Review Board (MRB)

· Recommendations for additional or alternative services needed in the Network area, e.g., self-dialysis training, transplantation, and organ procurement facilities.

The Network’s Board of Directors (BOD) will review and approve the report before the Network submits it to the COR.

The Network shall post the report on its website and, as directed by CMS, communicate the report’s availability to patients, family members/caregivers, the other Networks, ESRD providers and practitioners, members of Network-level and national renal-related LANs, and other members of the renal community.

See Exhibit J-4-3 for the Annual Report template.

V. Dashboard Input Form (DIF)

The Network shall use the CMS-approved DIF template and follow the CMS-specified criteria for reporting. The Network shall use the most current data available and shall submit data within the time frames specified in the SOD.

See Exhibit J-4-4 for the DIF template.

VI. Meeting Minutes

The Network shall submit all meeting minutes as directed by the SOW. CORs will determine which minutes to be delivered to them and the timeframe when they will be received. Minutes shall contain, at minimum:

· Date of meeting

· List of attendees

· Summary of meeting content.

VII. Information Technology

The Network shall adhere to the most current version of the policies and procedures outlined in “QualityNet System Security Policy” posted on the QualityNet website (www.qualitynet.org) and additional policies and procedures outlined in manuals posted on the NCC website (www.esrd.ncc.org). The documents on the NCC website include ESRD Networks IT support manuals and other security documentation.

The Network shall comply with all present and future statutes as well as Department of Health and Human Services (HHS), CMS, and other federal regulations and program instructions that relate to providing a secure computer operations environment. The Network shall comply with any future HHS, CMS, or other federal policies and procedures.

The Network shall establish a Network System Security Plan (SSP) which includes the Information Security Risk Assessment (RA) and maintain documentation about compliance with CMS security requirements as directed by CMS. The SSP/RA template is posted on the NCC website.

Upon request by CMS, the Network shall conduct an independent evaluation and test of its systems security program in accordance with “CMS Reporting Procedure for IS Assessments,” v5, and adhere to the prescribed template. This information can be obtained at www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/InformationSecurity/Downloads/Assessment_Rpting_Procedure.pdf.

The Networks shall keep a record of security incidents. When incidents occur, the Network shall follow the procedures and reporting requirements outlined in “QualityNet Incident Response Procedures” posted on the NCC website.

VIII. Required Reporting to the ESRD Network Coordinating Center (NCC)

As part of its role as a knowledge repository of Network-generated information, the NCC analyzes and interprets data provided by the Networks. The Network shall report data to the NCC as directed by the SOW and as otherwise directed by CMS.

To enable the NCC to fulfill its mission, the Network shall submit the following information to the COR and, upon COR approval, to the NCC:

· Emergency drill results

· Annual Report

· Cover letter to be included in the ESRD Patient Orientation Package (NEPOP)

· Contact information for Network patient representatives who will serve on the NCC LAN

· Patient contact information for grievance satisfaction surveys

· Best practices, such as successful interventions and system changes.

The Network may request ad hoc data reports from the NCC to support its Clinical AIMS–related work under the current SOW when the report is not available through other established means. The Network shall first get approval from the COR and then submit the request directly to the NCC on the appropriate NCC form (see CROWN Memo 14-0803-GN for template).

Exhibit J-4-1. Network COR Monthly Report Template

COR Monthly Report Instructions:

General:

For each component of the ESRD COR Monthly Report, please provide the specific information as delineated by the Statement of Work (SOW) and these instructions. Be concise and specific as possible. Bulleted items are permissible so long as the description is specific and clear enough to understand the concept being conveyed. The monthly report should not exceed 8 double-sided pages (or more than 16 total sides). Monthly reports shall be sent 3 business days before the scheduled monthly meeting/call with the COR and GTL.

Do not provide any listing of facilities that the Network is interacting with in any part of this deliverable. Individual facility identification is not necessary except in those situations where a specific facility is causing an issue, in which case the document shall be sent in compliance with CMS Security policy.

The numbers in parentheses refer to the deliverable number in the SOW. Do not remove this information from the complete form. If there is nothing to report for the month for a particular item, please indicate N/A for “Not Applicable” for this month in the right-hand column.

Place the Network # in the title. Do not send the instructions as part of the ESRD Network COR Monthly Report to the Contracting Officer’s Representative (COR). Separate the instructions from the reporting component of this deliverable and save as a separate file to me used on a monthly basis.

A. General Requirements:

1. Provide any critical issues identified through any minutes from any Network activity. Individual CORs will instruct the Network on whether they wish to receive copies of any Network activity minutes, and the timeframe of when they are to be received by the COR. Networks shall maintain copies of all minutes from committee meetings and make them available on request.

2. Provide a description of any Educational activities undertaken during the reporting month.

3. Provide a description of the assessment of the effectiveness of the educational activities undertaken during the previous month.

4. Describe any activities undertaken by the Network related to Emergency Preparedness.

5. Report the number of Security incidents the Network identified, and any actions taken by the Network if the Network identifies excessive security incidents within the Network.

6. Provide the statistics as request for the Network NEPOPs.

B. Foster Patient and Family Engagement at the Facility Level:

1. Describe any activities undertaken by the Network to foster Patient and Family Engagement at the facility level.

2. Provide the number of site visits to dialysis facilities (for any purpose). Provide a description of the Networks review of the seven (7) bullet points described under C.4.1.A.1.

C. State Survey Agency Activities:

1. Provide a description of the Network/SSA collaborative activities. Be concise, but specific.

2. Provide the number of Grievance Quality of Care cases which were referred to a State Survey Agency. Provide a brief description of any relevant facts related to the case and/or any follow-up conducted by the SSA of which you have been made aware, and any subsequent actions the Network may have taken related to the referral.

C. Patient Experience of care:

1. Provide a report of any findings or interventions related to the Focused Audit activities for which the Network is directed to accomplish in C.4.1.B.1

2. Provide a summary of any grievance (IA, grievance, Quality of Care, with or without referrals) cases which are of note. Identify any qualitative patterns or trends which should be brought forth to the COR. Document any specific Network actions to address any of the patterns/trends identified outside of those accomplished through the focused audit process.

3. Provide a summary of any access-to-care (IVD, IVT, F2P) cases which are of note. Identify any qualitative patterns or trends which should be brought forth to the COR. Document any specific Network actions to address any of the patterns/trends identified outside of those accomplished through the focused audit process.

4. Provide a summary of any issues and Network interventions related to the at-risk population of access-to-care cases.

5. Provide a summary of any patients for which the Network provided Office of Civil Rights referrals information. Do not include patients who contacted Network for general OCR information; that is, a case that is not directly related to a potential referral.

6. Provide a summary of any facilities for which the Network is considering, or is making a recommendation for sanctions. Provide a brief summary of the reasons the Network would like to make the recommendation. Do not identify the facility within this report.

7. Provide a summary of any activities related to the Grievance QIA.

8. Provide a summary of any activities related to promotion of ICH CAPHS undertaken by the Network under C.4.1.B.3.

9. Provide a summary of any activities related to the ICH CAPHS QIA.

D. Grievance Statistics: Provide the numbers (not percentages) for the data requested for the month reported. The columns totals should include both the ‘new’ and ‘continuing’ cases.

E. Access to Care Events: Provide the numbers for each row on the number of occurences or aversions that took place during the reporting month.

F. Access to Care Statistics: Provide the data as requested as whole numbers (i.e., counts). For Race, Ethnicity and Time since first Dialysis Facility (DF) Dialysis, provide the counts for the current month, and the cumulative (i.e., year to date) values. Follow definitions in the J-11 Attachment. Please total each section.

G. Vascular Access Management:

1. Report activities related to the Vascular Access Long-Term Catheter (LTC) QIA.

2. Report barriers and Network activities and intervention per C.4.1.D.2.

3. Report activities related to the provision of Technical Support in the area of Vascular Access. Please be specific and concise.

H. Patient Safety: HAIs:

1. Provide a summary of Network activities related to the HAI LAN. Be specific in describing Patient involvement with this activity.

2. Provide a summary of Network assistance with NHSN to facilities.

3. Monthly NHSN Data Check Results: Provide a summary of your activities and fill out the table.

4. Provide a summary of any Network activities related to the HAI BSI QIA.

5. Provide a summary of any Network activities related to the HAI Vaccination QIA.

I. Population Health Focused Pilot Projects: Please identify which Innovative Project and which disparity your NW selected. Provide a report of Network activities related to your specific PHFPP Project. In addition, report activity for attaining the project attributes. Be precise and concise. CORs will utilize this information to assess the Networks ability to meet the AIM2 project attribute requirements for evaluation purposes.

J. Support for ESRD QIP and Performance Improvement on QIP Measures:

1. Provide a summary of Network activities related to the activities in C.4.3.A.1.

2. Provide a summary of Network activities related to the QIP QIA.

K. CROWNWeb/Data Activities: Provide the requested data for each listed activity. In the “Number” column provide the number of events the Network received during the reporting month. In the “Number Resolved” column provide the number the Network was able to successful complete. In the “issues” right-hand column, provide any further information necessary to describe particular barriers or issues that need to be addressed. Use “Other Data Assistance” for activities not included in the categories listed, for example, NHSN, feedback reports, Medicare Advantage inquiries, UNOS verification, etc. Please identify the type of activity provided when using “Other Data Assistance”.

L. IQC Review and Analysis:

1. Review the IQC Plan and provide an analysis of any problem(s) that arise in performing contract requirements.

M. Other activities or emerging issues not listed in one of the above categories.

Date and Time_________________

Completed Date Received/Accepted

1.

2.

3.

4.

5.

III. Review Dashboard Input Form (DIF)

Identify specific project barriers/issues:

General Requirements

1. NC, BOD, MRB Minutes available upon request

2. Educational Activities undertaken

3. Educational Activity Effectiveness

4. Emergency Preparedness Activities

5. Security Incidents Reported ____

Total # mailed

# returned- death

# requiring address corrections

AIM 1: Better Care for the Individual through Beneficiary and Family Care:

1. Activities to foster Patient and Family Engagement at the Facility Level

2. Number of Site Visits ______ & Patient Engagement observations

1. Collaboration Activities

2. Grievance Referrals to SSAs Percent referred < 1 days_____

1. Focused Audit Findings and Interventions

2. Investigate/Resolve Grievances

3. IVD/IVT/F2P Investigations

4. Address patients at risk for Access-to-care issues

5. Patients provided referral information for OCR

6. Facilities recommended for Sanctions

7. Grievance QIA Activities

8. ICH CAPHS Promotion Activities

9. ICH CAPHS QIA Activities

New Cases opened this month

Continuing cases opened previously

Total Cases

1. IVDs Occurred

2. IVD’s Averted

3. IVTs Occurred

4. IVT Averted

5. F2Ps Occurred

Race

White

Black

Asian/PI

Am. Indian/AN

Total

Ethnicity

Hispanic

Non-Hispanic

Total

Time since First DF Dialysis

≤ 3 months

4 months to 1 year

1 year to 3 years

>3 years

Total

1. Reduce Catheter Rates for Prevalent Patients

2. Support Facility Vascular Access Reporting

3. Provide Technical Support in the area of Vascular Access

1. HAI LAN Activities

2. Provision of assistance with NHSN to facilities

# facilities that were notified

# facilities with errors in #1 – census denominator

# facilities with errors in #2 – VA denominator

# facilities with errors in #3 – no dialysis events x 3 mos

# facilities with errors in #4 – erroneous BSI rates

# facilities with errors in more than one activity

4. HAI BSI QIA Activities

5. HAI Vaccinations QIA Activities

AIM 2: Better Health for the ESRD Population

1. Project Specific Activities:

2. Innovation

3. Customer Focus

4. Rapid Cycle Improvement

5. Boundarilessness

6. Unconditional Teamwork

7. Sustainability

AIM 3: Reduce Costs of ESRD Care by Improving Care

1. Network activities related to CMS Performance assessment systems (QIP, DFC, Star Ratings, etc.):

2. QIP QIA Activities:

3. Data Quality QIA activities:

1. Add and Update Facility Details

2. Submit Facility Attestations

3. Admit Patients

4. Update Patient Records

5. Resolve Gap Patients

6. PART Verification

7. Add Key Personnel

8. Manage Clinical

9. Resolve Action List Notifications

10. Resolve Action List Accretions

11. Other Data Assistance

Totals

CMS 2744 Activities

1. IQC Review and Analysis of Problems that Arise in Performing Contract Requirements

Exhibit J-4-2. Semi-Annual Cost Report Template

CMS will notify the Networks when the CMS Semi-Annual Cost Report template is available and how to access it.

Exhibit J-4-3. Annual Report Template [DRAFT]

Table of Contents

Insert Table of Contents using Microsoft Word’s built-in Table of Contents formatting.

<INSERT PAGE BREAK HERE>

Executive Summary

The Executive Summary highlights the most important information in the report, giving the reader a snapshot of the report’s content.

Include, at minimum, outcome data for key performance measures.

The Executive Summary should stimulate a “wow” reaction on the reader’s part. The summary should be written in a manner that will easily convince the strongest critic that the Network and the ESRD Network Program as a whole have great value.

Recommended length: 1–2 pages.

Introduction

Use the following wording. Any deviations from this wording must be approved by the Network’s Contracting Officer’s Representative (COR).

CMS’ End Stage Renal Disease (ESRD) Network Organization Program The Centers for Medicare & Medicaid Services (CMS) is a federal agency, part of the U.S. Department of Health and Human Services. The End Stage Renal Disease Network Organization Program (ESRD Network Program) is a national program funded by CMS.

Under contract with CMS, 18 ESRD quality improvement organizations, known as ESRD Network Organizations or ESRD Networks, carry out a range of activities to improve the quality of care for individuals with ESRD. The 18 ESRD Networks serve the 50 states, the District of Columbia, and the U.S. territories of Puerto Rico, the Virgin Islands, American Samoa, Guam, and the Northern Mariana Islands.

CMS defines ESRD as permanent kidney failure in an individual who requires dialysis or kidney transplantation to sustain life.

Medicare Coverage for Individuals with ESRD Medicare coverage was extended to most ESRD patients in the U.S. under the Social Security Act Amendments of 1972 (Public Law 92-603). Individuals with irreversible kidney failure are eligible for Medicare if they need regular dialysis or have had a kidney transplant and they meet (or their spouse or parent meets) certain work history requirements under Social Security, the railroad retirement system, or federal employment.

History of CMS’ ESRD Network Organization Program Following passage of the 1972 Amendments to the Social Security Act, in response to the need for effective coordination of ESRD care, hospitals and other health care facilities were organized into Networks to enhance the delivery of services to people with ESRD.

In 1978, Public Law 95-292 modified the Social Security Act to allow for the coordination of dialysis and transplant services by linking dialysis facilities, transplant centers, hospitals, patients, physicians, nurses, social workers, and dietitians into Network Coordinating Councils, one for each of 32 administrative areas.

In 1988, CMS consolidated the 32 jurisdictions into 18 geographic areas and awarded contracts to 18 ESRD Network Organizations, now commonly known as ESRD Networks. The ESRD Networks, under the terms of their contracts with CMS, are responsible for: supporting use of the most appropriate treatment modalities to maximize quality of care and quality of life; encouraging treatment providers to support patients’ vocational rehabilitation and employment; collecting, validating, and analyzing patient registry data; identifying providers that do not contribute to the achievement of Network goals; and conducting onsite reviews of ESRD providers as necessary.

Role of <INSERT NETWORK NAME>’s in Improving the Quality of ESRD Care

In 1-2 pages, provide the following information (in any order):

The name of the ESRD Network The Network’s relationship (if any) with a larger corporate structure The geographic area served by the Network Any unique demographic or geographic characteristics of the Network area and/or ESRD patients in the Network area A summary of the various roles played by the Network in improving the quality of ESRD care; this should be a high-level overview, cross-referenced to outcomes reported later in the Annual Report.

Network Goals

As required by Section 1881 of the Social Security Act, insert a statement of the Network’s goals.

Profile of Patients in <INSERT NAME OF NETWORK>’s Service Area

The ESRD Network Program collects data on patient age, gender, race/ethnicity, primary diagnosis, and treatment modality for both incident (new) and prevalent (currently treated) ESRD patients. Data on the age and gender composition of the patient population are tracked for planning purposes; for example, an older population may require more personal care services than a younger population, while male and female patients may have different needs for services and support and may respond to different outreach efforts. The Program collects data on patients’ racial identification to allow tracking of disparities in care and outcomes.

Characteristics of the ESRD Population in <INSERT STATE(S)/JURISDICTION OR “the Network Area”>

Median age of prevalent patients as of December 31, <INSERT YEAR>

Percent female of prevalent patients as of December 31, <INSERT YEAR>

Reported race of prevalent patients as of December 31, <INSERT YEAR>

African American

Asian American

White

Other

Reported ethnicity of prevalent patients as of December 31, <INSERT YEAR>

Hispanic/Latino

Not Hispanic/Latino

Incidence (rate per 10,000 population)

Mortality

Prevalence (rate per 10,000)

Primary cause of ESRD (among incident patients)

Diabetes

Hypertension

Other

Treatment modality

In-center hemodialysis

Home dialysis

Vascular access type

Fistula

Graft

Catheter

Improving Care for ESRD Patients

In this section, report on contractually required and Network-initiated activities under the relevant heading. In describing successful Network activities and interventions, report measurable outcomes that are derived from objective, quantifiable data that have been gathered and analyzed systematically to assess the effect of an activity or intervention on a desired outcome (e.g., knowledge, behavior, lab value). Provide counts, percentages, difference scores, or other quantifiable data when presenting Network outcomes. Making general statements without providing quantifiable data to substantiate the claim being made is insufficient for the purpose of this section. Making general statements such as “the intervention decreased the number of inappropriate patient discharges” or “the learning module improved staff knowledge,” without providing quantifiable data to substantiate the claim being made is insufficient for the purpose of this section.

When describing a successful Network intervention:

Specify the target population (Example: dialysis facilities with high catheter rates) and why this target population was selected.

(If applicable) Indicate how project participants were selected/recruited. Specify any inclusion/exclusion criteria.

Describe what the Network did and (if applicable) what participants did in a way that will be understandable to a broad audience. Readers should be able to tell who did what, when, where, how, and why.

Specify quantitative and/or qualitative outcomes. Provide the numerator and denominator for all percentages/rates.

Describe steps taken, or to be taken, to ensure the sustainability of successful outcomes.

Vascular Access

Provide details on any successful Network activities in the area of vascular access.

Patient Safety

Provide details on any successful Network activities in the area of patient safety. Contractually required activities related to NSHN and HAIs will be reported as follows:

Support for the National Healthcare Safety Network (NHSN)

Discuss Network successes in meeting contractual requirements related to NHSN.

Healthcare-Acquired Infection LAN

Discuss Network successes in meeting contractual requirements related to reducing HAIs in dialysis facilities.

Support for the ESRD Quality Improvement Program (ESRD QIP)

Discuss any innovative approaches and successes in providing support for the ESRD QIP.

Provider Education

Describe what did the Network did that was new, exciting, and/or innovative in the area of provider education (e.g., outreach materials and activities, website development and utilization, newsletters). Report measurable outcomes of these educational activities and describe how the success of these activities was assessed. Making general statements without providing quantifiable data to substantiate the claim being made is insufficient for the purpose of this section.

Contributions to the Professional Literature

For every article published by Network staff and/or Network Board or committee members (if the Network is listed as the individual’s affiliation, alone or among other affiliations) in state or national academic journals or trade publications, provide the following information in list form or another appropriate format:

Author(s):

Title:

Name of journal/publication:

Publication date:

Volume (and issue if any):

Inclusive page numbers:

URL (if any):

Disparities in ESRD Care

Using data provided by the NCC, insert the following bar charts:

Rates per 10, 000 Population by Reported Race: Incident ESRD Patients, Prevalent Dialysis Patients, and Transplant Recipients (see sample chart below) Rates per 10, 000 Population by Reported Ethnicity: Incident ESRD Patients, Prevalent Dialysis Patients, and Transplant Recipients Transplant Recipients per 10, 000 Population, by Gender Transplant Recipients per 10, 000 Population, by Age Group

Rates per 10,000 Population by Reported Race: Incident ESRD Patients, Prevalent Dialysis Patients, and Transplant Recipients

Population Health Innovation Project

Identify the pilot project selected, briefly describe Network activities, including collaborations, describe how the success of these activities/collaborations was assessed, and report measurable outcomes of Network activities and collaborations.

Patient and Family Engagement

Patient Education

Describe what did the Network did that was new, exciting, and/or innovative in the area of patient education (e.g., outreach materials and activities, website development and utilization, newsletters). Report measurable outcomes of these educational activities and describe how the success of these activities was assessed. Making general statements without providing quantifiable data to substantiate the claim being made is insufficient for the purpose of this section.

Patient Engagement Learning and Action Network (LAN)

Summarize the activities of the Patient Engagement LAN and any measurable successes.

Support for ICH CAHPS

Provide details on any successful Network activities in supporting the ICH CAHPS.

Grievances and Access to Care

Grievances, Involuntary Discharges, Involuntary Transfers, and Failure to Place, Calendar Year <INSERT YEAR>

Number of Prevalent Dialysis Patients as of December 31,<INSERT YEAR>

Number of Grievances Filed with the Network in Calendar Year <INSERT YEAR>

Number of Non-Grievance Access to Care Cases Opened in Calendar Year <INSERT YEAR>

Number of Involuntary Discharges

Number of Failure to Place Cases

Grievances and Non-Grievance Access to Care Cases Referred to State Survey Agencies

Provide details on cases referred to the State Survey Agency(ies) including the resolution of the case wherever possible.

Recommendations for Sanctions

Provide details on recommendations for sanctions/alternative sanctions.

Recommendations to CMS for Additional Facilities

Provide recommendations for additional facilities and provide a rationale for such recommendations.

Emergency Preparedness and Response

Describe the Network’s efforts to provide education and services to patients with respect to emergency/disaster response during the calendar year. What educational offerings did Network staff attend to further their knowledge and understanding? What emergency preparedness education did the Network offer to patients?

If the Network responded to one or more emergency/disaster situations during the calendar year, briefly describe the situation(s) and provide details on the Network response.

If available, include measurable outcomes that are derived from objective, quantifiable data that have been gathered and analyzed systematically to assess the effect of Network activities in the area of emregency/disaster response.

Partnerships and Coalitions

Partnership with State Survey Agency(ies)

Briefly describe any collaborations with the State Survey Agency(ies) that have not been described elsewhere in the report.

Other Partnerships and Coalitions

Briefly describe any other new, innovative, and/or highly successful collaborative activities conducted by the Network. Describe how the success of these collaborations was assessed, and report measurable outcomes of the collaborations. Making general statements without providing quantifiable data to substantiate the claim being made is insufficient for the purpose of this section.

Appendix J-4-3.a. Network Staffing and Structure

The Network may use or modify the wording shown below under “Network Staffing.” At minimum, the “Network Staffing” section must include:

Name, graduate degree(s), brief background, role and responsibilities for each management staff member;

Number of part-time staff and number of full-time staff following directions provided below;

Table 1; font, font size, and background color can be modified in the table).

Network Staffing

Each of the 18 ESRD Networks employs a range of staff members who specialize in quality improvement, data management, beneficiary support, and other areas.

<INSERT NETWORK NAME> employs the following management staff:

· Project Director/Executive Director: <INSERT NAME, GRADUATE DEGREE(S), BRIEF BACKGROUND, ROLE AND RESPONSIBILITIES>

· Quality Improvement Director: <INSERT NAME, GRADUATE DEGREE(S), BRIEF BACKGROUND, ROLE AND RESPONSIBILITIES>

· Data Manager: <INSERT NAME, GRADUATE DEGREE(S), BRIEF BACKGROUND, ROLE AND RESPONSIBILITIES>

· Patient Services Director: <INSERT NAME, GRADUATE DEGREE(S), BRIEF BACKGROUND, ROLE AND RESPONSIBILITIES>.

Instructions for the following sentence: For full-time staff, give the number of full-time positions filled during the calendar year, regardless of whether the individuals holding any of the positions changed during the year. For part-time staff, give the total number of people who worked part-time, regardless of hours worked or length of employment. These numbers will not add up to the FTE total shown in Table 1.

In addition, the Network employed <INSERT NUMBER> full-time staff and <INSERT NUMBER> part-time staff in <INSERT YEAR>.

Discuss any major internal Network developments during the year (e.g., new Executive Director, change in corporate structure).

In <INSERT YEAR>, Network staff were allocated as follows:

Insert information into the following table.

Type of Employee

How to Calculate

Formula

ACTIVITY

Then multiply by the number of employees who work full-time on that activity.

For each employee:

1.0

Then, for each activity, add up these fractions across employees.

For each employee for each activity:

Hours per week spent on the given activity ÷ Hours worked per week

Then, for each activity, add up these fractions across employees.

For each employee:

Hours worked per week ÷ Hours worked per week by a full-time employee in your organization

Then, for each activity, add up these fractions across employees.

For each employee for each activity:

Hours per week spent on the given activity ÷ Hours worked per week by a full-time employee in your organization

TOTALS

*Example: A half-time employee devotes 50% of her time to quality improvement activities and 50% of her time to patient services. If she works 20 hours per week, and a full-time employee works 40 hours per week, then she spends 10/40 hours (0.25 FTE) on quality improvement and 10/40 hours (0.25 FTE) on patient services.

Network Boards and Committees

Describe the major activities and achievements of Networks Boards, committees,and subcommittees during the calendar year.

Appendix J-4-3.b. Dialysis Facilities and Transplant Centers in the Network Area

Number of Dialysis Facilities and Transplant Centers in the Network Area as of <INSERT DATE>

Insert information into the following table. Font, font size, and background color may be modified in the table.

Appendix J-4-3.c. Figures

Provide totals for the entire Network area in the following Figures. It is not necessary to provide subtotals by state if the Network area consists of more than one state.

Exhibit J-4-4. Dashboard Input Form (DIF)

CMS will notify the Networks when the current version of the DIF template is available and how to access it.

White Incident ESRD Patients, Calendar Year < INSERT YEAR > Prevalent ESRD Patients as of December 31, < INSERT YEAR > Transplant Recipients, Calendar Year < INSERT YEAR > 120 500 50 African American Incident ESRD Patients, Calendar Year < INSERT YEAR > Prevalent ESRD Patients as of December 31, < INSERT YEAR > Transplant Recipients, Calendar Year < INSERT YEAR > 150 800 20 Asian American Incident ESRD Patients, Calendar Year < INSERT YEAR > Prevalent ESRD Patients as of December 31, < INSERT YEAR > Transplant Recipients, Calendar Year < INSERT YEAR > 100 400 30 Other Incident ESRD Patients, Calendar Year < INSERT YEAR > Prevalent ESRD Patients as of December 31, < INSERT YEAR > Transplant Recipients, Calendar Year < INSERT YEAR > 50 50 10 Page 2 of 30 image1.png image2.png