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CROWNWeb Data Management
Guidelines - Role Of The
Facilities And The Network
IPRO Data Department 03/01/2016
2 2
Agenda
Data Submission Requirements
CROWNWeb Data Management Guidelines
“Data Managing” by Facilities
“Data Monitoring” by Network
3 3
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
4 4
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
5 5
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)
7 7
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
8 8
“Data Managing” Tasks – Tier 1 (Data Entry)
Facilities
Patients
Personnel
Clinical Action Lists
Form 2744
9 9
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
10 10
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
11 11
Facilities
Network can create a Facility
Demographics
Facility Details
Certification Information
Facility can review and edit limited information
Is the facility information accurate?
13 13
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
14
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
15 15
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
16 16
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
17
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
19
20 20
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
21 21
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
22 22
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
23 23
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
25 25
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
27 27
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
28 28
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
29 29
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
30 30
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-
DaVita DCI FMC NRAA HIE All Facilities
31 31
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
32 32
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
33
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/
35
37
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
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
43
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 (%)
49
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
51
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 [email protected]
52
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
53
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
54
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
56
57 57
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
58
59
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
Victoria Cash, MBA, BSN, RN Executive Director [email protected] Jaya Bhargava, PhD, CPHQ Interim Operations Director [email protected] Debbie DeWalt, MSN, BSN, RN Assistant Director, Quality Improvement [email protected] Andrea Bates, MSW Patient Services Director [email protected]
Kaszowski, Michelle Sr. Program Support Coordinator [email protected] Wendy Cable, RN, BA Information Systems Director [email protected] TBD Quality Improvement Coordinator [email protected] TBD Community Outreach Coordinator [email protected]
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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