ESRD NETWORK 6 2011 ANNUAL REPORT

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CMS Goal 5Improve the collection, reliability, timeliness, and use of data to measureprocesses of care and outcomes; to maintain a patient registry; and tosupport the goals of the ESRD Network Program.P a g e | 82
OverviewSoutheastern Kidney Council collects ESRD patient and facility data in Georgia, North Carolinaand South Carolina, thus providing crucial support and analysis of quality improvement andcommunity outreach activities to support the goals of the ESRD Networks. Previous sections ofthis report describe those activities.Southeastern Kidney Council enters and validates data through the Standard InformationManagement System (SIMS) as defined by CMS. Southeastern Kidney Council maintainsaccurate, complete, and current information for CMS-designated systems accounts. Networkstaff performs daily entry and analysis of data, and monthly validations to the active database.Data CollectionNetwork 6 processed 24,990 forms in 2011 (Table 9). The Network is responsible for obtainingcompleted CMS ESRD forms per the ESRD Network Organizations Manual. The followingnarratives describe how the Network met the goal of collecting data from facilities.Table 9. Number, type and description of forms entered into SIMS manually in 2011.CMS Forms Entered Manually into SIMS in 2011Form Form Description NumberEnteredCMS 2728 Medical Evidence The form is completed to determineMedicare entitlement for ESRD9,963CMS 2744 Facility SurveyCMS 2746 Death NotificationNetwork Patient Activity Report(NPAR) (Number of NPARS notevents)Vascular Access (non-LDO)The form is completed annually tovalidate all patient event data for theyear and capture treatment andstaffingThe form is completed for all expiredESRD patientsThe form is completed monthly toreport all patient events (new patient,receipt of transplant, transfer, death,etc)The form is collected monthly tocapture vascular access data for eachpatient5836,6266,626 forms37,762 events1,192Total Number of Forms Entered 24,990P a g e | 83
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“IMPROVING THE LIVES OF PEOPLE WI
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STATEMENT FROM THE BOARD OF DIRECTO
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Table of ContentsPREFACE ..........
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Contents of Figures and TablesFIGUR
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DATA TABLES LISTINGDATA TABLE 1: NE
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Network DescriptionESRD Network Pro
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Number of FacilitiesGENERAL POPULAT
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Number of PatientsGENERAL POPULATIO
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GENERAL POPULATIONESRD FacilitiesAt
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CORE VALUESIn achieving our Mission
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Quality ImprovementLeighann Sauls R
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Board of DirectorsThe Board of Dire
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Finance CommitteeIn 2011, the Board
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Medical Review BoardThe Medical Rev
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CMS NATIONAL GOALS & NETWORK ACTIVI
Page 31 and 32: The Quality of Care Commitment stat
Page 33 and 34: Network 6 Quality Improvement Progr
Page 35 and 36: Number of AVFsNumber of AVF in Use2
Page 37 and 38: Figure 15. AV Fistula Intervention
Page 39 and 40: Report 102 - VascularAccess Ranking
Page 41 and 42: Number of CathtersPROJECT 2: INCREA
Page 43 and 44: Intervention ImplementationSKC empl
Page 45 and 46: Figure 23. Progression of Network 6
Page 47 and 48: Feedback Reports to each focus faci
Page 49 and 50: Immunization Intervention overviewF
Page 51 and 52: Impact of the Southeastern Kidney C
Page 53 and 54: OverviewThe Network meets the expec
Page 55 and 56: Mental Healtho Living and Loving Li
Page 59 and 60: Medical Review Board and Board of D
Page 61 and 62: Patient Ambassador Pilot ProgramIn
Page 63 and 64: ole of Network 6, Dialysis Facility
Page 67 and 68: OverviewIn 2011, Southeastern Kidne
Page 69 and 70: CMS requires that Networks assume a
Page 71 and 72: Number of ContactsTechnical Assista
Page 73 and 74: Number of CallsNumber of CallsThe o
Page 75 and 76: CMS Goal 4Improve collaboration wit
Page 77 and 78: A collaborative project is a system
Page 79 and 80: State Survey AgenciesSoutheastern K
Page 81: Impact of the Southeastern Kidney C
Page 85 and 86: Data ValidationSoutheastern Kidney
Page 87 and 88: Technical AssistanceThe Southeaster
Page 91 and 92: Background and OverviewSoutheastern
Page 93 and 94: § 488.606 Alternative sanctions.(a
Page 95 and 96: Congress extended Medicarecoverage
Page 97 and 98: Return to routine monitoringHas fac
Page 99 and 100: 2011 Southeastern Kidney Council Sa
Page 101 and 102: RecommendationsPeople with end stag
Page 103 and 104: DATA TABLE 1: NETWORK 6 ESRD INCIDE
Page 105 and 106: DATA TABLE 2: NETWORK 6 ESRD PREVAL
Page 107 and 108: DATA TABLE 3: NETWORK 6 HOME DIALYS
Page 109 and 110: DATA TABLE 3: Network 6 HOME DIALYS
Page 123 and 124: DATA TABLE 4: NETWORK 6 IN-CENTER D
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DATA TABLE 4: NETWORK 6 IN-CENTER D
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DATA TABLE 5: NETWORK 6 NUMBER OF R
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DATA TABLE 6: Network 6 NUMBER OF R
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DATA TABLE 7 Network 6 DIALYSIS DEA
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DATA TABLE 8: NETWORK 6 VOCATIONAL
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ESRD NETWORK 6 2011 ANNUAL REPORT

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