ESRD NETWORK 6 2011 ANNUAL REPORT

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(timeliness and/or accuracy) and received monthly feedback reports. Staff re-measured inDecember 2011 for forms submitted January through December 2011, 26 facilitiesdemonstrated improvement. The Network continues to monitor accuracy and timeliness for allfacilities.Figure 36. Percent of Facilities that submitted forms on time by percent of forms submitted.Figure 37. Percent of Facilities that submitted accurate forms by percent of forms submitted.P a g e | 86
Technical AssistanceThe Southeastern Kidney Council provided technical assistance to facilities to improve datacollection, reliability and timeliness. In 2011, staff responded to approximately 650 inquires forassistance. The CMS 2728 form generated 44% of technical assistance inquires.Staff conducted two Education Information Calls during the year to assist facilities withcompleting the CMS 2728, CMS 2746 and the Network Patient Activity Report. Approximately70 participants attended the calls.VISION and QualityNet Electronic Data SubmissionSoutheastern Kidney Council supported 22 facilities using Vital Information Systems to ImproveOutcomes in Nephrology (VISION) during 2010. Each year staff validates 3% of CMS-2728forms submitted via VISION for physician and patient signatures. In 2011, VISION facilitiessubmitted 672 forms and both physician and patient signed 100% of the validated forms.Facilities use QualityNet Exchange to securely submit CMS 2728, 2746 and patient event data.In addition, dialysis facilities and CMS contractors use the system to submit other sensitive,patient-specific information to the Network. In 2011, facilities submitted 468 CMS-2728 formsand 323 CMS’ 2746 forms via QualityNet ExchangeMaintenance and Security of CMS EnvironmentNetwork staff provided technical support to maintain CMS hardware, software and patient data.Tasks included:Network server maintenance: This included troubleshooting problems with systembackups, replications and conductivity issues. Manual system backups and replicationsperformed as needed.Remedy: System used to maintain an accurate inventory of hardware and software inthe CMS environment, track tickets submit to the CMS contractor regarding systembackups, replications, conductivity issues and security breachesSecurity Awareness Training (SAT): The Network Security Point of Contact (SPOC)ensured all staff completed Security Awareness Training. Upon completion of trainingstaff printed a certificate to demonstrate completion of the course. Once all trainingcertificates are completed, SPOC provided information to CMS indicating all staffcompleted the CMS required security training.Business Continuity and Contingency Plan (BCCP): Network staff maintains a BCCP toensure the contingency and disaster recovery in the event of disasters that threaten theoperation of the Network or the security of patient data. The BCCP updated withpertinent personnel and vendor changes during 2011.P a g e | 87
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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
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The Quality of Care Commitment stat
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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 83 and 84: OverviewSoutheastern Kidney Council
Page 85: Data ValidationSoutheastern Kidney
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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