ESRD QIP National Healthcare Safety Network Combined Measure

$179 / year

This dataset includes facility details, National Healthcare Safety Network (NHSN) Bloodstream Infection (BSI) performance ratio, NHSN dialysis events number of months reported, NHSN combined measure score, and the state and national average measure scores. The NHSN dialysis event number of months reported and the NHSN bloodstream Infection ratio, which comprise the NHSN combined measure score are included in the PY 2019 End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP).

Complexity

The Centers for Medicare & Medicaid Services (CMS) administers the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) to promote high-quality services in outpatient dialysis facilities treating patients with ESRD. As the first of its kind in Medicare, this program changes the way CMS pays for the treatment of patients with ESRD by linking a portion of payment directly to facilities’ performance on quality of care measures. These types of programs are known as “pay-for-performance” or “value-based purchasing” (VBP) programs.

The ESRD QIP will reduce payments to ESRD facilities that do not meet or exceed certain performance standards. The maximum payment reduction CMS can apply to any facility is two percent. This reduction will apply to all payments for services performed by the facility receiving the reduction during the applicable Payment Year (PY).

National Healthcare Safety Network (NHSN) provides facilities, states, regions, and the nation with data needed to identify problem areas, measure progress of prevention efforts and ultimately eliminate Healthcare-Associated Infections (HAI). In addition, NHSN allows healthcare facilities to track blood safety errors and important healthcare process measures such as healthcare personnel influenza vaccine status and infection control adherence rates. NHSN enables healthcare facilities to collect and use data about HAIs, adherence to clinical practices known to prevent HAIs, the incidence or prevalence of multidrug-resistant organisms within their organizations, trends and coverage of healthcare personnel safety and vaccination, and adverse events related to the transfusion of blood and blood products.

In the NHSN Dialysis Event Protocol, the National Healthcare Safety Network (NHSN) Bloodstream Infection (BSI) in Hemodialysis Outpatients Measure is the standard for evaluating the number of positive blood cultures observed by a facility. Although other dialysis event types are reported to NHSN and calculated from the data, the BSI measure only assesses the number of positive blood cultures reported by a facility using a standardized infection ratio (SIR). Use of this measure has been demonstrated to help identify outbreaks of bloodstream infections and to stimulate improvements in vascular access care and other infection control practices that have led to subsequent reductions in bloodstream infections.

The foundation, principles, and mechanisms guiding the ESRD QIP will remain the same over time, but the program’s specific quality measures, standards, weights and formulas will change from year to year.

Date Created

2013-12-19

Last Modified

2020-01-22

Version

2020-01-22

Update Frequency

Quarterly

Temporal Coverage

2020

Spatial Coverage

United States

Source

John Snow Labs; Centers for Medicare and Medicaid Services;

Source License URL

Source License Requirements

N/A

Source Citation

N/A

Keywords

Dialysis Facility Compare, NHSN Combined Measure Score, NHSN Bloodstream Infection Ratio, Combined Quality Measures, ESRD QIP Combined National Healthcare Safety Network, NHSN BSI Performance Ratio, Healthcare-Associated Infections, Hemodialysis Outpatients Measure

Other Titles

National Healthcare Safety Network And Bloodstream Infection For Combined Measure, State and National Average Measure Scores For NHSN Combined Measure, ESRD QIP NHSN Combined Measure Score For PY 2019

NameDescriptionTypeConstraints
Facility_NameThe name of the Dialysis center or Facility.string-
CMS_Certification_Number_CCNCenter for Medicare & Medicaid Services (CMS) certification number (CCN). Identification number of the facility within the CMS dataset. The CCN for providers and suppliers is a 6 digit number. The first 2 digits identify the State in which the provider is located. The last 4 digits identify the type of facility.integerlevel : Nominal
Alternate_CCNIdentification number of the facility within the CMS dataset. The CCN for providers and suppliers is a 6 digit number. The first 2 digits identify the State in which the provider is located. The last 4 digits identify the type of facility.integerlevel : Nominal
AddressThe address of the dialysis center or facility.string-
CityThe city name in the location address of the facility being identified.string-
State_AbbreviationThe two-letter abbreviations of the state in the mailing address of the dialysis center. This includes information on hospitals in different U.S states.string-
Zip_CodeThe postal Zip code in the mailing address of the hospital.integerlevel : Nominal
NetworkIndicates the Network.integerlevel : Nominal
NHSN_BSI_Achievement_Measure_RateIdentifies the achievement measure rate in percentage of National Healthcare Safety Network (NHSN) Bloodstream Infection (BSI) measure.numberlevel : Ratio
NHSN_BSI_Measure_ScoreIndicates the score of the National Healthcare Safety Network (NHSN) Bloodstream Infection (BSI) measure.integerlevel : Ratio
NHSN_BSI_Reason_For_No_ScoreIndicates the reason for no score of National Healthcare Safety Network (NHSN) Bloodstream Infection (BSI) measure.string-
State_Average_NHSN_BSI_Measure_ScoreIdentifies the State Average score of National Healthcare Safety Network (NHSN) Bloodstream Infection (BSI) Measure. This measure indicates the number of months for which facility reports NHSN Dialysis Event data to the Centers for Disease Control and Prevention (CDC).integerlevel : Ratio
National_Average_NHSN_BSI_Measure_ScoreIdentifies the National Average score of National Healthcare Safety Network (NHSN) Bloodstream Infection (BSI) measure. This measure indicates the number of months for which facility reports NHSN Dialysis Event data to the Centers for Disease Control and Prevention (CDC).integerlevel : Ratio
NHSN_Dialysis_Event_Reporting_Measure_ScoreIdentifies the reporting score of dialysis event for National Healthcare Safety Network (NHSN) measure.integerlevel : Ratio
NHSN_Dialysis_Event_Reporting_Reason_For_No_ScoreIndicates the reason for no score of dialysis event reporting for National Healthcare Safety Network (NHSN) measure.string-
NHSN_Dialysis_Event_Reporting_Number_of_Months_ReportedIdentifies the number of reported months for dialysis event reporting of National Healthcare Safety Network (NHSN) measure.integerlevel : Ratio
State_Average_NHSN_Dialysis_Event_Reporting_Measure_ScoreIndicates the state average score for dialysis event reporting of National Healthcare Safety Network (NHSN) measure.integerlevel : Ratio
National_Average_NHSN_Dialysis_Event_Reporting_Measure_ScoreIndicates the national average score for dialysis event reporting of National Healthcare Safety Network (NHSN) measure.integerlevel : Ratio
NHSN_Combined_Measure_ScoreIndicates the combined score of National Healthcare Safety Network (NHSN) measure.integerlevel : Ratio
NHSN_Combined_Reason_For_No_ScoreIndicates the combined reason for no score of National Healthcare Safety Network (NHSN) measure.string-
State_Average_NHSN_Combined_Measure_ScoreIndicates the state average combined score of National Healthcare Safety Network (NHSN) measure.integerlevel : Ratio
National_Average_NHSN_Combined_Measure_ScoreIndicates the national average combined score of National Healthcare Safety Network (NHSN) measure.integerlevel : Ratio
Facility NameCMS Certification Number CCNAlternate CCNAddressCityState AbbreviationZip CodeNetworkNHSN BSI Achievement Measure RateNHSN BSI Measure ScoreNHSN BSI Reason For No ScoreState Average NHSN BSI Measure ScoreNational Average NHSN BSI Measure ScoreNHSN Dialysis Event Reporting Measure ScoreNHSN Dialysis Event Reporting Reason For No ScoreNHSN Dialysis Event Reporting Number of Months ReportedState Average NHSN Dialysis Event Reporting Measure ScoreNational Average NHSN Dialysis Event Reporting Measure ScoreNHSN Combined Measure ScoreNHSN Combined Reason For No ScoreState Average NHSN Combined Measure ScoreNational Average NHSN Combined Measure Score
CHILDRENS HOSPITAL DIALYSIS1230613300.01600 7TH AVENUE SOUTHBIRMINGHAMAL3523383.3186610121010487
FMC CAPITOL CITY12500255 S JACKSON STREETMONTGOMERYAL3610480.9385.06610121010787
GADSDEN DIALYSIS12501409 SOUTH FIRST STREETGADSDENAL3590181.3644.06610121010687
TUSCALOOSA UNIVERSITY DIALYSIS12502220 15TH STREETTUSCALOOSAAL3540180.7726.06610121010887
PCD MONTGOMERY125051001 FOREST AVENUEMONTGOMERYAL3610682.3526610121010487
DOTHAN DIALYSIS12506216 GRACELAND DR.DOTHANAL3630580.73400000000000016.06610121010887
FMC MOBILE125072620 OLD SHELL RDMOBILEAL3660780.5427.06610121010887
BIRMINGHAM EAST DIALYSIS125081105 EAST PARK DRIVEBIRMINGHAMAL3523580.228.06610121010987
FMC NORTH ALABAMA125091311 N MEMORIAL PKWY #200HUNTSVILLEAL3580180.1919.06610121010987
FMC SELMA12512905 MEDICAL CENTER PARKWAYSELMAAL3670180.7596.06610121010887