State Survey / Surveyor Data Dictionary (Network 1, 6, 9)

Updated 8/13/2025

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Abbreviations & Acronym	Meaning
BL	Baseline
BY	Base Year (First year of the current CMS 5-year ESRD contract)
C (1-7)	Coalition project group. Highest number is the most current active group
DQ	Data Quality
ED	Emergency Department
EQRS	ESRD Quality Reporting System
ESRD	End Stage Renal Disease
ICHD	Incenter Hemodialysis
HCP	Healthcare Professional
HHD	Home Hemodialysis
HE	Health Equity
HL	Healthy Living
KR	Key Result
OY	Option Year (2nd-4th years of the current CMS 5-year ESRD contract)
PD	Peritoneal Dialysis
PFE	Patient Family Engagement
QAPI	Quality Assessment and Performance Improvement
QIA	Quality Improvement Activities
Txp	Transplant/Waitlist
Vax	Vaccination/Vaccines

Facility Management

Network requirements for facilities, separate from EQRS/QIP but required as part of the Network Agreement.

Emergency Preparedness Critical Access Survey: Updated annually each September by facility, includes emergency contacts and planned activities.
Network/Facility Agreement of Participation: Required to complete upon initial CMS certification, available to update as needed.
Coalition: Groups of facilities assigned special projects for 6-month duration. Once C1 ends, C2 begins, then when C2 ends, C3 begins, etc.
OY IPRO Learn Compliance Completed Rate: Learning Management System required for facilities to participate. Each year resets the score, counting completion rate of required activities that year.

Facility QIP Score

Most current facility rate and prior year rate, with payment reduction over time.

Immediate Jeopardy Information

Immediate Jeopardy (IJ): (State Survey Agency Terminology) situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death.
Dates and outcomes of any Patient Immediate Jeopardy cases opened by/at the facility.
If table blank = none.

Patient Experience of Care (PEoC) Case Types

Types and quantities of patient care cases opened by/at the facility during this CMS contract – broken out by years.
- Access to Care: Patient is “at-risk” or “confirmed” losing their admission status at a facility, or has difficulty accessing care due to: behavior, medical need, or facility refusal.
- Clinical Quality of Care: The rights of two or more patients have been violated OR service received from a facility did not meet professionally recognized standards of clinical care and/or professional conduct.
- Facility Concern: Patient/staff have a concern related to the facility, that does not meet criteria of Grievance nor Access To Care case.
- General Grievance: Communication from a patient/representative alleging that the facility did not meet professionally recognized standards with respect to safety, civility, patient rights, and/or clinical standards of care.
- Immediate Advocacy (IA): Simple, generally non-quality of care cases that can be completed in 10 calendar days or less
- Patient Concern: General concern from a patient that does not meet criteria of Grievance nor Access To Care case.

QIA Facility Report Card Details

CMS-required, Network-assigned annual facility goals. Network sends monthly Report Cards to all facility staff on file, with detailed progress towards goal.

Key Result Outcomes		Definition
KR02 Home: Incident Patients	↑	Number of ‘New ESRD’ patients starting dialysis using a home modality. - PD or HHD within the first 90 days. Never had incenter modality as their primary modality within a specified time frame. Data source -EQRS.
KR04 Home: Prevalent Patients	↑	Number ESRD patients starting on a home modality – PD or HHD after 90 days. Data source -EQRS.
KR05 Transplant: Waitlist	↑	Number of patients added to the transplant waitlist after completing evaluation at transplant center and found to be good candidates for transplant. Transplant centers have different eligibility criteria. Data source- EQRS.
KR06 Transplant: Transplanted	↑	Number of Patients who receive kidney transplants in a specified time frame. Data source -EQRS.
KR16 Vax-Influenza Patient	↑	Number of patients who have received their annual influenza vaccines. Facility goals- Increase the percentage of patients receiving influenza vaccination (>90%). Data source – EQRS.
KR23 Vax- Pneumococcal Patients	↑	Number of eligible patients who have completed their pneumonia vaccination series (fully vaccinated). Data source EQRS.
KR25 Hosp: Hospital Admissions	↓	The count of ESRD-related inpatient hospital admissions. Data source -EQRS & Medicare Claims.
KR30 Hosp: Outpatient ED Visits	↓	Number of ESRD-related outpatient emergency department visits. Data source -EQRS & Medicare Claims.
KR31 PFE: QAPI	↑	QAPI- Quality Assessment and Performance Improvement- A goal of patient and family engagement is to create a culture of shared responsibility for improvement within the facility. Facility Goal- increase the number of patients and family’s participation in QAPI. Source: Self-reported.
KR33 PFE: Life Plan	↑	A life plan is a roadmap to help patients get the things that mean the most to them and is built around personal goals and dreams. The healthcare team focuses on additional external factors contributing to patients’ outcomes in conjunction with the traditional care plan. Facility goal- increase the number of patients with documented life plans. Source: Self-reported.
KR35 SPF: Patient Support Program	↑	Any activity aimed at transferring best practices within the facility (patient to patient engagement ) or outside of the facility (patients engaged in external support group activities). Peer mentorship and Patient Facility Representatives fall in this OKR. Facility goal- Increase patient support programs Source: Self-reported.
KR37 DQ QIA: 2728 Forms within 45 Days	↑	ESRD Medical Evidence Report Medicare Entitlement And/or Patient Registration Forms- required to add a patient to the ESRD registry and help them apply for Medicare benefits- Due within 45 days of the Admit Date. Measure- Percentage of 2728 Forms submitted within 45 days in the last 12 months. Data source EQRS.
KR38 DQ QIA: 2746 Forms within 14 Days	↑	Death Notification- required by CMS to be submitted in EQRS within 14 days of the patient's date of death (DOD). Measure- Percentage of 2746 Forms submitted within 14 days in the last 12 months. Data source EQRS.
Depression Screening	↑	Percent of Medicare patients screened for depression, with results reported in EQRS. Data source EQRS.

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