CROWNWeb Data Management

Guidelines - Role Of The

Facilities And The Network

IPRO Data Department 03/01/2016

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Agenda

Data Submission Requirements

CROWNWeb Data Management Guidelines

“Data Managing” by Facilities

“Data Monitoring” by Network

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Conditions For Coverage

494.180(h) ‐ Standard: Furnishing data and information for ESRD program administration. Effective February 1, 2009, the dialysis facility must furnish data and information to CMS and at intervals as specified by the Secretary. This information is used in a national ESRD information system and in compilations relevant to program administration, including claims processing and reimbursement, quality improvement, and performance assessment. Be submitted at the intervals specified by the Secretary;

(2) Be submitted electronically in the format specified by the Secretary;

(3) Include, but not be limited to—

(i) Cost reports;

(ii) ESRD administrative forms;

(iii) Patient survival information; and

(iv) Existing ESRD clinical performance measures, and any future clinical performance standards

developed in accordance with a voluntary consensus standards process identified by the Secretary. The Conditions for Coverage for End‐Stage Renal Disease Facilities (http://www.cms.hhs.gov/CFCsAndCoPs/downloads/ESRDfinalru le0415.pdf) published in April 2008 outline the need for CROWNWeb on page 20484

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CROWNWeb Data Submission

CROWNWeb is “National ESRD patient registry”

Facilities to follow Centers for Medicare and Medicaid Services’ (CMS) requirements for data submission into CROWNWeb using “Data Management Guidelines”

ESRD Networks are to monitor CROWNWeb data submission compliance by facilities

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CROWNWeb Supports CMS Goals

Optimize health outcomes as part of the CMS Quality Strategy

Promote high‐quality patient care

Support ESRD Quality Incentive Program (ESRD QIP)

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CY 2016 and PY 2018

NHSN

NHSN

Claims

CW

Claims

Claims

Claims

ICH CAHPS

Claims/CW

Claims

CW

CW

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Data Management Guidelines

Standardized data management Processes

Separated by tasks and tiers

Three tasks

Data Monitoring (Data quality - accuracy, timeliness etc)

Data Measuring (Data comparison to a criteria)

Data Managing (Data collection)

Three tiers

Tier 1 – enter data directly into CROWNWeb, Facilities, Batch, NRAA-HIE

Tier 2 – provide technical data reporting assistance, Networks

Tier 3 – support CMS data reporting needs, Help desk

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“Data Managing” Tasks – Tier 1 (Data Entry)

Facilities

Patients

Personnel

Clinical Action Lists

Form 2744

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Commonly Used Abbreviations in CROWNWeb

What is a CCN?

CMS Certification Number (CCN) =

6-digit ESRD Medicare Provider assigned to facility (xxxxxx)

What is UPI?

Unique Patient Identifier

A unique number assigned to a patient record in CROWNWeb when a patient is admitted

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Facilities

Network Monitors Facility Attestations • Send general email • Send emails to facilities

missing data

Facility details • Enters new facility • Updates changes

Tier 1

Tier 2

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Facilities

Network can create a Facility

Demographics

Facility Details

Certification Information

Facility can review and edit limited information

Is the facility information accurate?

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Patient Data

Tier 1

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Patient Data- Batch and Manual Submission

Tier 1 - Data Managing

DaVita DCI FMC NRAA

HIE

Independent

Facilities

Patent Data

submitted-

Batch

Every Mon Every Tues

and Thu

Every Mon

and Wed

Patent Data

submitted-

Manually

Daily

Electronic data

interchange (EDI) Any Time

PART

Verification 5th Business day of the following month

Tier 2 - Data Monitoring: Send email / call “Unverified PART” to

facilities that did not verify PART

PART Verification

Tier 1 - Verify “PART” by 5th Business day of following month

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PART verification for all patients should be completed by the end of each month – no later than the 5th business day of the following month

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Benefits of PART Verification

Balances 2744 surveys

Allows smooth clinical data submission by batch

Problems related to “First event not new to ESRD” resolved

Allow timely submission of 2728 and 2746 forms

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Complete 2728 and 2746 Forms

Tier 2 - Data monitoring

The Network sends emails with “Missing Forms Report” to facilities on monthly basis

Complete CMS‐2728 and CMS‐2746 Forms

within 10 business days of Date Regular Chronic Dialysis Began; no later than 45; CMS‐2746: within 14 days of the date of death

Tier 1 - Data managing

Save & Submit

Save: Can make changes to 2728 and 2746 forms

Submit:

Review before the forms are submitted.

Once the form is submitted it cannot be changed by facility staff or network staff.

A help desk ticket has to be submitted.

If the information that is being requested changes the benefits period, CMS contractor can request for records

Save: Clinical data is not considered reported if it is in saved format

Submit: Once submitted it can be changed until the month is closed

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ICD-10-CM List of Primary Causes of Renal Failure

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Action List Consists of Notifications and Accretions

Notifications: A discrepancy in patient data between CROWNWeb and other the Centers for Medicare and Medicaid Services (CMS) data systems.

Accretions: A patient from another CMS data source that is not in CROWNWeb

Network and Facilities work on action list on a monthly basis

Action List

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Action List

Resolve Notifications and Accretions New or Reassigned:

within 15 days of issuance; Under Investigation: within 30 days of issuance

Tier 2 - Data monitoring : The Network sends emails with “Outstanding Action Items Report” to facilities on monthly basis

Tier 1 - Data managing

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About Action Items…..

Dialysis Facility Data

System

LDO’s CROWNWeb

Other CMS DATA

SYSTEMS

Submitted Data

Rejected Data

Rejected Data Reports DaVita = Fix it report FMC = Batch Error Report NRAA HIE = CROWNWeb Errors DCI = BRES

Action Items

Updating facility data systems when CROWNWeb “Action Items” are processed leads to less errors on Rejected Data received from your corporation

Fix in your facility data system

Fix in your facility data system

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Tier 2 - Patient Data

Week Task Facilities Verifies (NW recommendation)

Network Monitors

1 PART 5th Business day Network sends “Unverified PART Report” Emails

2 Missing forms

Verified by 10th (see DMG)

Network sends “Missing Forms Report” Emails

3 Action list Process Weekly to meet 15 day compliance – update LDO data system (see DMG)

Network sends “Outstanding Action Items Report” Emails

4 Data Clean Up

First admission not new to ESRD, transient and system discharges etc

Network Sends “Data Clean Up Report” Emails (specially during survey period)

4 Clinical data

Verifies last week of the month

Network sends missing clinical data reports

Network Monthly Data Management Cycle

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Personnel

CROWNWeb is the authoritative source of emails for Network

It is provider responsibility to keep the information current

Personnel information can be updated in CROWNWeb under “Personnel” tab

Anyone with access to CROWNWeb can update facility personnel information.

Information regarding key staff members (name, Job Description, JOBCODE, job title, e-mail, and phone number) has to be entered in CROWNWeb.

Add Key Personnel Within 5 business days of staff changes

Tier 1 - Data managing

Tier 2 - Data Monitoring: The Network reminds facilities

View Personnel Screen

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Facilities Verify Personnel information

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Job Description JOBCODE

Facility Head Nurse/Nurse Supervisor FHNNS

Facility Social Worker FSW

Facility Dietitian FDIET

Facility Medical Director FMD

Facility Administrator FADM

Facility Nephrologist FNEPH

Facility Data Contact FDC

Key personnel Info – complete all the information Positions – create as many positions as required. For Personnel with scope over several facilities, remove the position. Do not delete the personnel or inactivate them. One can add and remove as many positions as possible. Personnel Contact Info – Email is required.

Key staff members with JOBCODE

Personnel Details Screen

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Hemodialysis clinical data Peritoneal dialysis clinical data Vascular access data Data for each month is due in CROWNWeb by the end of the

2nd month Batch data submitted by Large Dialysis Organizations

Clinical And Vascular Access Data

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Tier 1 - Clinical Data

DaVita DCI FMC NRAA HIE Independent

Facilities

Clinical Data Uploaded

/submitted manually

Full clinical

data

submission on

15th day of

the following

month or next

business day

Full clinical

data

submission

on Second

Tuesday in

the following

month

Full clinical

data

submission

on 2nd

Monday in

the following

month

As soon as

facilities

submit data

to NRAA

HIE.

By last day

of the

month

Clinical data

completeness verified

by every facility

After 25th Last week Last week Last week Last week

Batch and EDI data submission

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Tier 2 - Clinical Data

Week Task Facilities Complete Network Monitors

1 PART 5th Working day Network sends “Unverified PART Report” Emails

2 Missing forms

Verified by 10th (see DMG)

Network sends “Missing Forms Report” Emails

3 Action list Weekly – update LDO data system (see DMG)

Network sends “Outstanding Action Items Report” Emails

4 Data Clean Up

First admission not new to ESRD, transient and system discharges etc

Network Sends “Data Clean Up Report” Emails (specially during survey period)

4 Clinical data

Verifies last week of the month

Network sends missing clinical data reports

Network Monthly Data Management Cycle

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Help desks

CROWNWeb

Education Lead FMC Help Desk:

866-491-8167

NRAA Help Desk

Form

(http://www.for

mstack.com/form

s/?1228399-

P1hy2crrdK)

CROWN Help desk

866-288-8912

qnetsupport-

esrd@hcqis.org

DaVita DCI FMC NRAA HIE All Facilities

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2744 Deadlines

January 1, 2016 - February 15, 2016: Regenerate and begin review, data cleanup and initial submission of CMS-2744 survey in CROWNWeb for year 2015

April 1, 2016: Final due date for submission to the ESRD Network for approval

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2744 Process

Step 1: In CROWNWeb, click on Form 2744 tab. Click “Search”. Enter

your facility Medicare Number and click on “Go” go to populate the facility name. Enter the survey year as “2015”. Then click “Submit”.

Once the form opens up, enter treatment and staffing information. Verify Vocational Rehabilitation information

When the form is completed click “submit”. Step2: The Network verifies the data and then “Accepts” the form. Step3: If the data is incomplete the Network will “Reject” the form. Step4: If the data is complete, the Network will submit the form as

“Finalized”.

Access to CROWNWeb

Security Awareness Training (SAT)

Create a QualityNet Identity Management System (QIMS) account Part A - general QIMS account information ESRD Application Access Form (EAAF)

Defines a user’s CROWNWeb role and scope Defines a users QIP role and scope

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QualityNet ESRD Facilities tab

You can register for a QIMS account through

this page.

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Three Types of QIMS Account

Security Official (SO) – Two user ID’s End User Manager (EUM) – One user ID End Users – One user ID

Each facility should have one EUM and one SO at all times Each facility should have one “ Facility Point of Contact”

Create a “Facility Point of Contact” for QIP

Each facility has one person with access as “Facility Point of Contact” to print “Performance Score Certificate”

http://esrd.ipro.org/initiatives/data-systems-and-reporting/crownweb-2/

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PART A Application

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Part A Form Signature Requirements

Applicant cannot sign the form as their own EUM or SO If the applicant is the first user at the facility,

Applicant should be an SO PART A form has to be notarized

When completing the online PART A application Applicant should select Master Manger Applicant should select Master Security Official

Applicant is the first EUM / second user at the facility, PART A form can be signed by facility SO Select facility SO and Master Manager when completing the online

PART A application

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EAAF Form

Login to CROWNWeb

Click ESRD Facilities www.qualitynet.org

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CW Login Screen

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CMS Warning

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Two Factor Authentication (TFA)

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How to change the way TFA code is received?

Go to www.qualitynet.org

Click ESRD tab

On left hand side click Manage QIMS account

You will be brought to a screen identical to CW login screen; Enter your CW id and password

Click Accept on the warning screen

Click Profile tab, then Account Attributes

Scroll down to Preferred TFA Method and select method: Email, Phone number or Cell phone number

At the bottom of the screen enter your CW password & click Save

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QIMS Home Page

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*EUM approves other users

*

Profile Screen

Change password

Setup/update authentication questions

To change TFA

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Account Attributes Screen

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Account Attributes Screen (cont’d)

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CROWNWeb Useful Features

Wildcards Breadcrumbs

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What is a Wildcard?

A wildcard is a symbol entered into a field when one is uncertain of search criteria

CW allows a percent (%) for wildcard searching in fields marked with a percent (%)

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Breadcrumbs

A breadcrumb will help get back to a previous screen

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Edit information

CROWNWeb always opens as “View only” mode.

Any screen that gives the ability to edit will have an “Edit…”button in the grey bar to the top left of each page

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QualityNet Help Desk

If you need assistance with the registration process contact the QualityNet Help Desk at: 866-288-8912 (Monday - Friday 8am to 8pm EST) or via e-mail at qnetsupport-esrd@hcqis.org

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Reports

Reports Patient Forms: Download blank forms and Instructions Run Audit Forms Report Run Saved forms report Run Notification and Accretions Reports Run some clinical data reports

My Reports Will show the reports that have been generated

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http://mycrownweb.org Admit a New Patient View and Verify PART Data Notifications and Accretions – Facility Role

Facility Add, Edit, and Delete Facility Personnel

Completing the CMS-2728 Form Completing the CMS-2746 Form Completing the CMS-2744 Form – Facility Role

http://mycrownweb.org/education/crownweb-training-videos/

http://mycrownweb.org/education/training-courses/

Training and Education

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Tutorials

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NHSN Data Management

Dialysis Module Annual Survey - annually Dialysis Event Data submission – quarterly but the Network

recommends monthly Data quality Checks - quarterly Run CMS - ESRD - QIP report – quarterly

Healthcare Personnel Influenza Vaccination Reporting plan HCP vaccination data

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DialysisData.org

Facility Master Account UserId and Password

Create users

Annually enable users

Facility User accounts

Comment on DFC and DFR

Download DFR and DFC reports

Common CMS Systems / Roles

Role System System Description Related Systems Login ID

Looks Like

Suggested

Staff to have

access

NHSN Administrator NHSN Report Dialysis Events;

Staff Vaccinations Email

(+SAMS

card for

code)

NM, RN, AA

QIMS

- Security Official;

- End User Manager

QIMS Approve, Disable and Edit

QIMS User Accounts

CROWNWeb; QIP

1.0.0 xx1111 SW, AA (SO)

NM (EUM)

MD

CROWNWeb

- Facility Administrator

- Facility Editor and/or

- Facility Viewer

CROWNWeb CMS Data System for

Facility, Patient and

Clinical Data

QIMS;

QIP 1.0.0 xx1111

NM, MD

SW, AA

QIP 1.0.0

- Point of Contact

- Facility Viewer

QIP 1.0.0 View, Download and

Comment on PSRs and

PSCs

QIMS; CROWNWeb xx1111 NM, AA,

MD (Facility

POC)

Dialysis Data.org

- Master Account Holder

DialysisData.

org

Enable/Disable Accounts;

Add/Remove Permissions CCN NM

DialysisData.org

- Regular User

DialysisData

.org

View/Edit/Comment on

DFR and QDFC

Email MD, NM

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Data Submission Final Thought

CROWNWeb Data – Follow data management guidelines

Infection data in NHSN - End of quarter after each quarter

Data may come from anywhere – each facility is responsible for

the accuracy and completeness of their own data

Contacts

Victoria Cash, MBA, BSN, RN Executive Director vcash@nw9.esrd.net Jaya Bhargava, PhD, CPHQ Interim Operations Director jbhargava@nw9.esrd.net Debbie DeWalt, MSN, BSN, RN Assistant Director, Quality Improvement ddewalt@nw9.esrd.net Andrea Bates, MSW Patient Services Director abates@nw9.esrd.net

Kaszowski, Michelle Sr. Program Support Coordinator MKaszowski@nw9.esrd.net Wendy Cable, RN, BA Information Systems Director Wcable@nw9.esrd.net TBD Quality Improvement Coordinator TBD@nw9.esrd.net TBD Community Outreach Coordinator TBD@nw9.esrd.net

3201 Enterprise Parkway, Suite 201, Beachwood, OH 44122 Phone: (203) 387-9932 Fax: (203) 389-9902

IPRO ESRD Network of The Ohio River Valley (Network 9)

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IPRO ESRD Program Website http://esrd.ipro.org

For more information

IPRO ESRD Program http://esrd.ipro.org

CORPORATE HEADQUARTERS

1979 Marcus Avenue

Lake Success, NY 11042-1002

www.ipro.org