NHSN and CMS End Stage Renal Dialysis Quality Incentive Program (ESRD QIP) Rule
NHSN Enrollment and Training
Which types of dialysis facilities are required to participate in the Centers for Medicare and Medicaid Services (CMS) End Stage Renal Disease (ESRD) Quality Incentive Program (QIP) National Healthcare Safety Network (NHSN) Dialysis Event Reporting Measure?
The CMS ESRD QIP NHSN reporting measure only applies to facilities that treat hemodialysis patients in-center. Facilities treating 10 or fewer patients are excluded. For purposes of the NHSN Dialysis Event reporting measure, CMS determines whether a facility meets these criteria by referencing the facility's information in CMS data sources (that is, SIMS and CROWNWeb). For more information, please see the CMS ESRD QIP rule [PDF - 2.14 MB].
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 - 245 KB] and report:
- Calendar year 2012 (payment year 2014): a minimum of 3 consecutive months of 2012 data. These data must be reported to NHSN no later than April 30, 2013
- Calendar year 2013 (payment year 2015): 6 to 12 months of 2013 data. Facilities must report a minimum of 6 months to be awarded points; additional points will be awarded incrementally for reporting more than 6 months of data. These data must be reported to NHSN no later than April 15, 2014.
Reporting the full 12 months is strongly encouraged by both CDC and CMS to increase familiarity of the facility with the process of reporting to NHSN and to improve data quality and quality improvement efforts.
What do I need to do in order to report?
In order for a dialysis facility’s data to be reported to NHSN and sent to CMS, a facility must:
- Complete required training
- Complete all enrollment steps
- Enroll in NHSN individually (i.e., each dialysis facility reporting needs a unique NHSN organization identification number (org ID))
- Enroll in NHSN as an 'AMB-HEMO – Hemodialysis Center' facility type
- Input a correct CMS Certification Number (CCN) into NHSN
- Report data following the NHSN protocol
If you are already participating in NHSN, you can verify both facility type and CCN within NHSN by clicking on "Facility" and then "Facility Info" on the NHSN navigation bar and reviewing the "Facility Information" section.
How does CMS score the ESRD QIP NHSN Reporting Measure?
Facilities must complete training and enroll in NHSN prior to reporting data to fulfill the requirements of this reporting measure.
CMS scoring criteria are outlined in the final CMS ESRD QIP Rules:
- For Calendar Year 2012 (Payment Year 2014) see the Federal Register, volume 76, number 218, section II.B.4.vi, page 70273-4.
- For Calendar Year 2013 (Payment Year 2015) see the Federal Register, volume 77, number 218, III.D.9.c, page 67506.
Measurement is at the individual facility level; at least one staff member at each facility must be trained in and knowledgeable of how to report dialysis event data to NHSN. At least one facility staff member should have a digital certificate and access to NHSN.
NHSN Enrollment and Training
When should we start enrolling our facility into NHSN to meet reporting deadlines for the CMS ESRD QIP rule?
Enrollment is a one-time process; once your facility is enrolled in NHSN, no additional enrollment steps are required to continue reporting indefinitely.
Facilities that did not enroll in 2012, but plan to participate in NHSN for the QIP in performance year 2013, should begin enrollment as early in 2013 as possible. An Outpatient Dialysis Center Practices Survey [PDF - 128 KB] is required as part of the enrollment process. This survey includes questions that are specific to the first week of January, so users are strongly encouraged to collect these data in January, regardless of when in 2013 they plan to initiate NHSN enrollment.
NHSN enrollment consists of several steps. Although each facility’s timeline is different, allow at least 4-6 weeks to complete enrollment. Facilities that belong to a corporate dialysis chain are encouraged to contact their corporate headquarters to determine if an enrollment plan has already been established for their facility.
Where do I start?
Begin by completing the required training on the Outpatient Dialysis Facility Training page. Once you have completed your required training, you can enroll your facility in NHSN or if your facility is already enrolled, ask a user with administrator rights to add you as a user [PDF - 177 KB] for the facility.
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:
- NHSN Enrollment for Outpatient Dialysis Facilities
- NHSN Set-up for Outpatient Dialysis Facilities
- Training format: watch the 13 minute set-up video
- Required for: users who have enrolled one or more facilities and for other users assigned administrator user rights
- Dialysis Event Surveillance Protocol
- Training format:
- Required for: all dialysis facility users, regardless of user rights or roles, and for non-users who are involved in data collection
Users should complete training before getting started in NHSN. Each user’s training completion date is required prior to gaining access to the system. The training completion date is the date the user completed their required training, as listed above.
My hospital-based facility has more than one associated CMS Certification Number (CCN) (i.e., a hospital CCN and a dialysis CCN). Which CCN should I use for my facility in NHSN?
Hospital-based facilities with more than one CCN may register under either their hospital CCN or their dialysis CCN and receive credit for ESRD QIP scoring. Each dialysis facility should register in NHSN only once, but can use either CCN.
Do I need a new digital certificate for each dialysis clinic I enroll?
No, digital certificates are user-specific. Only one digital certificate is required for each user, as long as they enroll each facility using the same email address each time. Instructions for enrolling multiple dialysis facilities with a single digital certificate are available here: Enrolling Multiple Outpatient Dialysis Clinics in NHSN [PDF 1.65 MB]
Do I need a new digital certificate for each dialysis facility of which I am a user?
No, digital certificates are user-specific. Only one digital certificate is required for each user, as long as they are added as user to each NHSN facility (and/or group) with the same email address each time.
My dialysis facility is already enrolled and reporting, is there anything I need to do?
Yes, if your facility is already enrolled and reporting, please verify:
- Your facility information: from the NHSN navigation bar, select "Facility" and then "Facility Info" and check:
- The facility type is 'AMB-HEMO – Hemodialysis Center.' If it is not, contact the NHSN Helpdesk for assistance.
- The CMS Certification Number (CCN) is correct. If it is not correct, revise it and save changes on this screen.
- Your facility is reporting data according to the Dialysis Event Protocol [PDF - 245 KB]. This requires all persons involved in data collection and reporting understand the protocol and surveillance definitions.
If outpatient dialysis services are contracted, who is responsible for reporting to NHSN?
It is up to the organization/dialysis facility to decide whether or not they are interested in participating in NHSN reporting. If they decide to participate, then they must also decide who will be responsible for tracking and entering the required data to NHSN. The person(s) conducting this data collection and data reporting are responsible for completing the training and following the reporting requirements as specified in the Dialysis Event Protocol [PDF - 245 KB].
How should NHSN user roles be assigned given challenges related to staff turnover?
Each NHSN facility should have at least two users with administrator rights to simplify issues related to staff turnover. If the NHSN Facility Administrator will be leaving a facility, he or she needs to reassign their NHSN Facility Administrator role to another NHSN user before his or her departure. All NHSN users who no longer work for a specific facility should be deactivated immediately.
If your facility is enrolled, but does not have current staff members with access to NHSN, contact the NHSN Helpdesk at email@example.com for assistance.
What data will CDC share with CMS about dialysis facilities participating in Dialysis Event surveillance?
For performance year 2012, using the list of ESRD CMS Certification Numbers (CCNs) provided to CDC by CMS, CDC will confirm whether a facility with a corresponding CCN is enrolled in NHSN, and whether or not data were reported to NHSN according to the Dialysis Event Protocol for each month.
Data sharing for performance year 2013 has yet to be determined.
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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