Frequently Asked Questions

NHSN and CMS End Stage Renal Dialysis Quality Incentive Program (ESRD QIP) Rule

Reporting

What do I have to report to NHSN for the CMS ESRD QIP rule?

Facilities reporting to NHSN for the CMS ESRD QIP rule must follow the Dialysis Event Protocol [PDF - 342 KB] for a minimum of 3 consecutive months in 2012.

What do I need to do in order to report?

Complete enrollment guidance can be found at NHSN Enrollment for Dialysis Facilities

In order for a dialysis facility’s data to be reported to NHSN and sent to CMS, a facility must:

1. Complete required training
2. Complete all enrollment steps
   1. Enroll in NHSN individually (i.e., each dialysis facility reporting needs a unique NHSN organization identification number (org ID))
   2. Enroll in NHSN as an ‘AMB-HEMO – Hemodialysis Center’ facility type
   3. Input a correct CMS Certification Number (CCN) into NHSN
3. Report data following the NHSN protocol

If you are already participating in NHSN, you can verify both CCN and facility type within NHSN by clicking on "Facility" and then "Facility Info" on the NHSN navigation bar and reviewing the "Facility Information" section.

When do I need to start reporting?

Facilities must begin reporting no later than October 1, 2012 but are encouraged to start as early as possible. Facilities should complete the enrollment survey in January 2012.

How many months do I need to report data to NHSN for the CMS ESRD QIP rule?

For 2012, three consecutive months of data must be reported to NHSN in order to comply with the CMS ESRD QIP rule.

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NHSN Enrollment and Training

When should we start enrolling our facility into NHSN to meet reporting deadlines for the CMS ESRD QIP rule?

NHSN enrollment consists of several steps.Although each facility’s timeline is different, allow at least 4-6 weeks to complete enrollment. Users are encouraged to contact their corporate headquarters or ESRD Network to determine if there is a suggested enrollment schedule for their facility.

Users are encouraged to begin enrollment as early as possible and before July 2012.

Data collection must begin no later than October 1, 2012, and be conducted according to the Dialysis Event Protocol [PDF - 342 KB].

Where do I start?

A. There is a process for getting started in NHSN. The first step is reviewing the required training materials on the Dialysis Event website to learn how to enroll your facility into NSHN, learn what data will need to be collected, and learn how to use NHSN to report those data. Once you have completed this required training, you can begin enrolling your facility. NHSN Enrollment is a 5 step process that occurs over the course of a few weeks. Please visit NHSN Enrollment for Dialysis Facilities for an overview of the process and corresponding resources.

What is the required training to get started in NHSN?

Required training materials are listed on the Dialysis Event website. There are three main areas of training for new users:

1. The NHSN enrollment and set-up process*
2. Understanding data collection requirements (includes reading the Dialysis Event Protocol [PDF - 342 KB] and becoming familiar with data collection forms)
3. How to use NHSN to report data

Users should review training materials before getting started. The date training was completed is requested during enrollment.

*Only the person enrolling the facility is required to complete enrollment training, users who are added after the facility is enrolled should review the remaining requirements.

The dialysis clinic and hospital have the same CMS Certification Number (CCN), do I still need to enroll the dialysis clinic separately?

Yes, dialysis clinics must be enrolled in NHSN individually as an ‘AMB-HEMO – Hemodialysis Center’ facility type to report data to CMS, even if the dialysis clinic is hospital affiliated.

Multiple facilities can be enrolled with a single digital certificate.See instructions here: Enrolling Multiple Outpatient Dialysis Clinics in NHSN [PDF 1.65 MB]

Do I need a new digital certificate for each dialysis clinic I enroll?

No, you can enroll multiple facilities with a single digital certificate as long as you use the same e-mail address each time. Instructions for enrolling multiple dialysis facilities are available here: Enrolling Multiple Outpatient Dialysis Clinics in NHSN [PDF 1.65 MB]

My dialysis facility is already enrolled and reporting, is there anything I need to do?

Yes, from the NHSN navigation bar, select "Facility" and then "Facility Information."Under the "Facility Information" section, verify that your facility type is ‘AMB-HEMO – Hemodialysis Center.’ If you are not enrolled as 'AMB-HEMO Hemodialysis Center’ contact the NHSN Helpdesk for instructions.Also under the "Facility Information" section, verify that your CMS Certification Number (CCN) is correct. If it is not correct, you can revise it and save changes on this screen. Also verify that your facility is reporting data according to the Dialysis Event Protocol [PDF - 342 KB] (i.e., you have entered a reporting plan for all months you intend to report following the protocol).

I have to change how my facility is enrolled in NHSN. Can I keep my old data that had been reported to NHSN?

Yes, if you need to enroll your dialysis facility separately to report under the CMS QIP rule, but would like your data to be available in NHSN, contact the NHSN Helpdesk at nhsn@cdc.gov. In your email, include the old NHSN org ID, name of location(s) of old data, the new NHSN org ID, and the name of location(s) where new data should be moved.

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Electronic Reporting - Clinical Document Architecture

If our facility plans to use clinical document architecture (CDA) to report data electronically to NHSN, do we still need to enroll in NHSN?

Yes, facilities using CDA still need to enroll, add an ‘Outpatient Hemodialysis Clinic’ location, and complete the annual Outpatient Dialysis Center Practices Survey manually.

When will clinical document architecture (CDA) be ready for Dialysis Event surveillance?

CDA is currently under development for the Dialysis Event module. It is anticipated to be ready in August 2012; however, users should plan to complete data entry manually until CDA is available and it has been verified that data are being captured correctly.

Facilities that plan to use CDA for reporting still need to enroll, add an ‘Outpatient Hemodialysis Clinic’ location, and complete the annual Outpatient Dialysis Center Practices Survey manually.

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General

Who do I contact with CMS ESRD QIP rule questions that are not related to NHSN?

Contact CMS at ESRDQIP@cms.hhs.gov for non-NHSN ESRD QIP rule questions.

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