ESRD NETWORK 6 2011 ANNUAL REPORT

Data ValidationSoutheastern Kidney Council analyzes data received at several points in the process, beginningwith a visual edit at the point of receipt. As staff enters forms into the SIMS database, thedatabase performs system edits that notify the entry specialist if data is incomplete orinaccurate. The system checks for missing data and inconsistent data (such as date of birthlater than first date of dialysis). SKC returns forms that fail the edit checks to the facility forcorrection. On average, Southeastern Kidney Council has to reject about 20% of 2728 forms(Medical Evidence Report) and about 3% of 2746 forms (Death Notifications).In addition to point of entry edits, staff performs monthly data analysis and clean up. TheNetwork runs approximately 85 independent checks to locate data issues and anomalies. Manyof these issues are reliant on more than one form, so point of entry checks alone would notcatch the issues. The Network performed analysis and cleaned 23,156 records. For example,the clean up catches:Patients who have been reported as transferring out of a facility, but have not yet beenreported by the receiving facility (dangling transfers)New ESRD patients reported by more than one facilityDuplicate patient records when a patient is reported on two forms and demographics donot matchFacility record with no personnel reported in key positionsSoutheastern Kidney Council receives notifications and accretions from CMS to update andcomplete data elements. Notifications are additional or changed data elements for existingpatients and may include updates received through the Social Security office or throughMedicare. Southeastern Kidney Council averages about 1600 notifications per month.Accretions are patients added to the system. This often includes transplant patients for whomno facility has submitted a 2728 and may include patients already in the system who havesignificantly different information in the CMS system. Southeastern Kidney Council averagesapproximately 15 accretions per month.Data ComplianceAfter data entry and cleanup, staff track and report facilities’compliance (Table 10) with submitting CMS forms accurately(Figure 37) and on time (Figure 36). CMS requires all ESRDfacilities to maintain a compliance rate of 90% or better foraccuracy and timeliness.Table 10. Percent of Network 6 CMS formscompliance by year and form.NW Semi-annualCompliance 2010Southeastern Kidney Council implemented a targetedintervention with 26 facilities to help improve compliance inJanuary 2011. Network 6 directed facilities to online tools toassist with increasing compliance rate, attended a27282746Combined85.6%93.2%88.7%mandatory conference call with Southeastern Kidney Council focusing on their compliance issueRate2728 85.0%2746 93.1%Combined 88.2%NW Annual Compliance2010 RateP a g e | 85