Goals and Recommendations - 2021

All Network 3 facilities will:

  • Meet the reporting requirements and maintain expected levels of clinical performance to meet or exceed the CMS Clinical Performance Standards as reported in the Finalized PY 2023 Quality Incentive Program.      
2021 Goals Chart
Source: Federal Register (https://www.govinfo.gov/content/pkg/FR-2019-11-08/pdf/2019-24063.pdf)

* On these measures, a lower rate indicates better performance.

**Minimum Goal - This is the CMS ESRD QIP Final PY 2023 Performance Standard, which, is the 50th percentile of performance rates nationally during CY 2019. Facilities that meet this goal may not achieve the full points for the specified measure. 

***Top 10% Nationwide - This is the CMS ESRD QIP Final PY 2023 Benchmark, which is the 90th percentile (Best 10% of units) of performance rates nationally during CY 2019. Facilities that meet or exceed these rates will likely earn the full points for the specified measure. 

CfC Interpretative Guidelines, § 494.110 Condition: Quality assessment and performance improvement (V628) states, “Where minimum outcome values have been determined, facilities are expected to provide care directed at achievement of at least the minimum outcome value by all patients.”  

Facilities that have achieved the minimum goals shall strive to meet or exceed the top 10% goals. 
  • Assess and refer in a timely manner medically suitable patients to treatment modalities that increase rehabilitation and independence including in-center self-care, home self-care and transplantation.  
  • NJ specific - NJ state regulations require a transplant surgeon or designee is a part of the plan of care interdisciplinary team. (N.J.A.C Title 8 Chapter 43 8:43A-24.13 Patient care plan).  
  • Establish and maintain a quality assessment and performance improvement program that evaluates the care provided and identifies opportunities for and continuously works to improve care delivered. 
  • Clearly delineate and respect the rights and responsibilities of both the patient, family, significant others and the facility while promoting patient/family centered care and engagement. 
  • Submit data and information timely and accurately as defined by project to the Network and in End Stage Renal Disease Quality Reporting System (EQRS) as is required by law and regulation.   
  • Register in NHSN, enroll in the Network 3 group and submit dialysis event data and information timely and accurately on a monthly basis. 
  • Designate two disaster representatives for the facility and provide alternate contact information in EQRS for primary and secondary disaster personnel.  
  • Notify the ESRD Network of key personnel changes. 
  • Assist the Network in the identification and referral of Patient Advisory Committee representatives. 
  • Make available to patients Network-provided information on its Quality Improvement Projects, the national QIP, the Annual Report, Regional and National profiles of care, the importance of immunization, information on how to access and use Medicare’s Dialysis Facility Compare Report, information on the EQRS system developed by CMS and other information as directed by the project. 
  • PR specific - As a result of the collaborative meeting held in October 2019, facilities will ensure the facility transplant designee attend an annual transplant designee program. 
  • NJ facilities - Report reportable events including emergency situations that disrupt dialysis delivery 
    through NoviSurvey. For guidance on how to report in NoviSource, email NonLTC.Reportables@doh.nj.gov



MRB approved: 02/10/2021
BOD approved: 

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