Qsource ESRD Education Series
Quality Incentive Program (QIP) Overview
Learning Objectives
- Explain the purpose of the ESRD Quality Incentive Program (QIP).
- Describe the general QIP scoring and payment timeline.
- Summarize how achievement, improvement, and weighted scoring contribute to the Total Performance Score.
- Recognize how QIP performance connects to facility quality improvement efforts.
- Identify practical strategies to reduce the risk of payment penalties.
- Locate QIP reports and understand the importance of the preview period.
Qsource ESRD Network
ESRD Networks
ESRD Networks work in partnership with dialysis facilities to strengthen the systems that support patient care. Through shared data, clinical oversight, and targeted quality initiatives, ESRD Networks help teams focus improvement efforts where they have the greatest impact on outcomes that influence morbidity, mortality, and cost, including sepsis.
The Role of the ESRD Network
The ESRD Network partners with facilities throughout this process, serving as a convenor, organizer, motivator, and change agent. Networks support teams by:
- Bringing stakeholders together around shared goals.
- Providing structure, tools, and data to guide improvement.
- Encouraging experimentation and learning.
- Helping translate small tests of change into sustainable practice.
Quality Improvement Initiatives
Medical Review Board Oversight
Emergency Preparedness & Response
Designs, supports, and monitors QI activities that target high-risk outcomes.
Provides clinical review, guidance, and accountability for quality and safety concerns.
Supports facilities and patients before, during, and after emergencies and disasters.
What Does the ESRD Network Do?
+ info
Patient Experience of Care
EQRS Data Management & Reporting
Community & Partner Collaboration
Promotes patient-centered care, engagement, and grievance resolution.
Convenes providers, patients, and community partners to spread best practices and accelerate improvement.
Ensures accurate data collection, reporting, and use for performance improvement.
+ info
Why the Quality Incentive Program (QIP) Matters
Why QIP Matters
- The ESRD QIP is a CMS program that evaluates dialysis facility performance on quality measures and links that performance to payment.
- Understanding QIP helps facility leaders and staff interpret scores, monitor risk, and support better patient outcomes.
- Facilities receive a Total Performance Score (TPS) based on measured performance.
- Facilities that fall below performance thresholds may receive a payment reduction of up to 2%.
What Impacts Your QIP Score
- QIP focuses on what care is delivered and the outcomes it produces.
- Measures and domains evolve over time to reflect priorities in care.
- Scores are based on performance across multiple domains and measures.
- Some facilities may not receive a TPS due to low patient eligibility, not poor performance.
Rulemaking and Scoring Timeline
Rulemaking Process
Each year, CMS updates QIP through a federal rulemaking process. The general sequence is:
June- August
September- October
November
Start
June
CMS reviews comments and develops the final rule
CMS publishes the proposed rule in the Federal Register
HHS approves, and CMS publishes the final rule in the Federal Register
Public 60-day comment period
HHS reviews proposals
Why Timing Matters in QIP
QIP scoring is not immediate, it follows a multi-year cycle:
Year 2: Review & Finalize
Year 1: Data Collection
Year 3: Payment Impact
Your facility’s performance is captured across multiple systems (EQRS, NHSN, CAHPS, Medicare billing).
Final scores determine whether CMS applies a payment reduction.
You are given a limited 30-day window to review your performance scores, verify accuracy, and request corrections. Final Performance Score Reports are then released.
Example: Payment Year 2028 Measurement Period
What you do today impacts payment two years from now.
2026
2024
Performance Year or Calendar Year (CY)
Achievement Period
2028
2025
Payment Year
Improvement Period
Although we have used Payment Year 2028 as an example, please remember that depending on what Payment Year you are looking at, QIP Domains and Measures will differ. Refer to the website link below to utilize specific Payment Year Technical Specs outside of PY 2028. Refer to the website links below to utilize specific Payment Year Manuals and Technical Specs.
Link to ESRD QIP
QIP Domains and Measures
QIP Domains and Measures
- The five ESRD QIP domains align with the CMS's Meaningful Measures Initiative, targeting high-impact areas that influence patient outcomes and care quality.
- Each measure carries a specific weight, so higher-weighted measures have a greater influence on the Total Performance Score (TPS).
- Measure scores are calculated, weighted, and combined to produce the overall TPS.
- To receive a TPS, a facility must be eligible to receive a score on at least one measure in two domains.
Not all facilities will receive a Total Performance Score (TPS) due to low patient volume or a limited number of eligible cases. Importantly, the absence of a TPS does not equal poor performance. It often reflects data limitations rather than care quality.
QIP Domains and Measures PY 2028
The Total Performance Score is made up of five measure domains:
Reporting
Patient & Family Engagement
15%
10%
Safety
10%
30%
Care Coordination
35%
Clinical Care
Click on the plus signs to learn more about the individual measures in each domain.
Individual QIP Measures Removed From Previous Payment Years
As the ESRD QIP evolves, measures may be added, updated, or removed to reflect changing priorities in healthcare quality and reporting.Measures removed in recent Payment Years include:
- PY 2026: Facility Commitment to Health Equity
- PY 2026: NHSN Dialysis Event Reporting Measure
- PY 2027: Screening for Social Drivers of Health & Screen Positive Rate for Social Drivers of Health Measures
These changes reflect ongoing efforts by the CMS to:
- Align measures with current data capabilities
- Reduce reporting burden where appropriate
- Focus on measures that most effectively drive meaningful patient outcomes
How Scoring Works
To get the most out of this section, locate your latest performance score report and refer to it as you review your facility’s scoring.
How Scoring Works
Measures are scored using achievement and improvement scoring models.
- Achievement scoring
- Compares your facility's performance on a measure during the performance period to the performance of all facilities nationally during the comparison period. (2 years prior).
- Improvement scoring
- Compares your facility's performance on a measure during the performance period to its own performance during the baseline period.
The facility receives the higher of the two scores for a measure. Measure scores generally range from 0 to 10.
Improvement Score Methodology
Click on the information buttons for more.
Improvement Threshold
2026 Performance Period Rate
Benchmark
Improvement Score = 1-9
Improvement Score = 10
Improvement Score = 0
2026 Performance Period Rate
The orange line shows your facility’s current performance. Where it lands determines your score.
Improvement Score Example
Care Coordination Measure: Clinical Depression Screening and Follow-Up
Improvement Period Denominator
Performance Period Numerator
Performance Period Denominator
Improvement Period Numerator
Improvement Period Rate/Ratio
73
100
73.00%
87
92
Achievement Score
Performance Period Rate/Ratio
Achievement Threshold
Improvement Score
Benchmark
100%
94.57%
87.10%
Measure Weight (% of Domain)
Achievement Threshold
Measure Score
20.66%
Improvement Score Formula
If the facility's performance period rate falls within the improvement range, the improvement score will result between 1 and 9 using this formula:
Facility's Performance Period Rate Improvement Threshold
10 x
- 0.5
Benchmark Improvement Threshold
Improvement Score Example
94.57-73
Facility’s Performance Period Rate: 94.57% Improvement Threshold (2024 Rate): 73% Benchmark 100%
10 x
- 0.5
100-73
21.57
7.4
- 0.5
10 x
27
Final Measure Score = 7
Achievement Score Methodology
Hover over the information buttons for more.
2026 Performance Period Rate
Achievement Threshold
Benchmark
Achievement Benchmark Score
Below Achievement Threshold Score
Achievement Range Score
Achievement Score Formula
If the facility's performance period rate falls within the achievement range, the achievement score will result between 1 and 10 using this formula:
Facility's Performance Period Rate Achievement Threshold
9 x
+ 0.5
Benchmark Achievement Threshold
Achievement Score Example
Care Coordination Measure: Clinical Depression Screening and Follow-Up
Improvement Period Denominator
Performance Period Numerator
Performance Period Denominator
Improvement Period Numerator
Improvement Period Rate/Ratio
73
100
73.00%
87
92
Achievement Score
Performance Period Rate/Ratio
Achievement Threshold
Improvement Score
Benchmark
100%
94.57%
87.10%
Measure Weight (% of Domain)
Achievement Threshold
Measure Score
20.66%
Achievement Score Example
94.57-87.10
Facility's Performance Period Rate: 94.57%Achievement Threshold: 87.10%Benchmark: 100%
9 x
+ 0.5
100-87.10
7.47
5.7 (round to 6)
+ 0.5
9 x
12.9
Final Score = 6
Measure Score Determination
Care Coordination Measure: Clinical Depression Screening and Follow-Up
Improvement Period Denominator
Performance Period Numerator
Performance Period Denominator
Improvement Period Numerator
Improvement Period Rate/Ratio
73
100
73.00%
87
92
Achievement Score
Performance Period Rate/Ratio
Achievement Threshold
Improvement Score
Benchmark
100%
94.57%
87.10%
Measure Weight (% of Domain)
- Improvement Score= 7
- Achievement Score=6
- Final Measure Score= 7 (Takes the highest of the two scores)
Achievement Threshold
Measure Score
20.66%
Weighted Measure Scores
QIP uses a weighted scoring system to reflect the relative importance of different measures and domains.Each measure is assigned a weight:
- Higher-weighted measures contribute more heavily to the final score.
- Lower-weighted measures have less impact.
- These weighted scores are then combined to calculate the Total Performance Score (TPS).
Example: Care Coordination Measure Domain PY 2028
Each of these four measures contributes equally to the Care Coordination domain score.
2 + 2 + 1.75 + 2.5
x 10 =
82.5 Care Coordination Domain Score
Total Performance Score PY 2028
TPS = 90.72 = 91%
Missing Measures and/or Domains
- Facilities are only scored on measures where they meet eligibility criteria.
- If no measures apply within a domain, that domain is excluded from the score calculation.
- Instead of penalizing the facility, QIP redistributes that domain’s weight across the remaining domains.
- This ensures the TPS is still calculated fairly based on available data.
- For more details, utilize the Payment Year (PY) Program Details Manual to dive into how the redistribution process is applied.
Payment Year Total Performance Scores and Payment Reductions
PY 2028 *Varies from year to year
Preview Period, Reports, and Certificates
QIP Preview Period
Facilities have an opportunity to review their scores during the QIP Preview Period, which usually lasts about 30 days in the summer. During this time, facilities can review calculations and submit inquiries if they believe errors occurred.
- Preview reports should be reviewed promptly.
- Each facility's point of contact can download their facility's Preview Performance Score Report (PSR) or send an inquiry.
- Facilities may submit an unlimited number of inquiries during the preview period.
- Early communication and submission of inquiries to CMS is strongly encouraged.
Submitting Inquiries
1.
Log into EQRS
Inquiries may be submitted for:
- Questions about scores included in their Performance Score Report
- More than one question can be included in the inquiry
- Requests for further examination
2.
Click "QIP Scores"
3.
Click "Period Inquiries"
4.
Follow the steps provided on the page
Performance Score Reports (PSRs) and Certificates (PSCs)
Click on the View/Download Reports tab
Step 1
Step 4
Log into EQRS
Reports are accessed through EQRS and require: - A HARP account
- A QIP user role
Enter/select your facility and any filtering options
Click on the nine dots in the upper left corner and select “QIP”
Step 2
Step 5
Click “Apply Filter” and then click on the hyperlinked report and download
Link: PY 2026 Guide to the UI
Enter/select your organization and click on “Go to QIP”
Step 3
Step 6
• Must remain posted until the next payment year PSC is available
• Must be displayed in a prominent patient area
• Must be displayed in English and Spanish
Certificates must be posted within 15 business days.
Sample Certificate
Sample Link
QIP and Quality Improvement
QIP tells you what the problem is. QI tells you how to fix it.
QIP Measures Reflect the Quality of Care Delivered
QIP measures are designed to evaluate real patient outcomes and care processes, such as:
- Dialysis adequacy (Kt/V)
- Infection rates
- Catheter use
- Readmissions and hospitalizations
- Patient experience (ICH CAHPS)
Quality improvement (QI) focuses on closing gaps between current performance and desired outcomes, which directly affects how a facility scores on these measures.
QI provides the framework to:
Identify Root Causes
Analyze Trends
QI
Prioritize Risk Areas
Re-Measure Results
Implement Targeted Interventions
Example: Quality Improvement in Action
Examples:Low Kt/V scores
- QI project evaluates treatment time,
- blood flow rates,
- access issues,
- missed treatments
High catheter rates
- QI targets referral timing,
- vascular access tracking,
- surgeon availability
QI Aligns Clinical, Operational, and Regulatory Goals
Strong QI programs help facilities:
- Improve patient outcomes
- Reduce variation in care
- Strengthen staff accountability
- Support compliance with CMS Conditions for Coverage
- Reduce financial risk from QIP payment reductions
QI allows leaders to explain not only results, but the actions taken to improve them.
Surveyors and CMS Expect a QI Response to QIP Results
Facilities are expected to:
- Review their Performance Score Reports
- Identify low-scoring measures
- Implement Performance Improvement Projects (PIPs)
- Monitor effectiveness and sustain gains
A lack of documented QI activity related to poor QIP performance may result in:
- Negative survey findings
- Network follow-up
- Ongoing poor scores and payment reductions
Quality Improvement is how facilities actively manage ESRD QIP performance.
Without QI, QIP becomes reactive. With QI, QIP becomes a strategic tool to drive better care, stronger outcomes, and financial stability.
Preventing QIP Penalties
Not all measures carry the same weight. - While every measure plays a role in performance, some have a greater impact on outcomes.
- Take a strategic approach by prioritizing key measures and domains that drive meaningful, sustainable improvements at your facility.
Tip:- Start each year by reviewing your current Performance Score Report (PSR) and circle:
- Measures scoring below national benchmarks
- Measures trending downward
These should become QI priorities, not just data points.
Tips to Avoid QIP Penalties
Know Your QIP Measures and Prioritize Your Risks
1.
Best Practices:- Assign responsibility to a specific role (administrator, QI lead)
- Understand when reporting data deadlines are that affect certain measures.
- Review scores as soon as they’re released
- Use the preview period to:
- Validate data accuracy
- Submit corrections if needed
- Start improvement work immediately
Review Performance Score Reports Early and Often
2.
Facilities receive a Preview Performance Score Report before final scores are applied.
Tip:Waiting until the Final PSR limits your ability to respond and may lock in a penalty.
QIP scoring uses the higher of achievement or improvement.If your facility is below benchmarks: - You can still avoid penalties by showing measurable improvement
- Improvement scores are often easier to achieve with focused QI work
Tip:Every low-performing QIP measure should have:
- A documented PIP or QI action plan
- Clear targets
- Monthly monitoring
3.
Use Quality Improvement to Capture Improvement Points
High-risk measures to monitor monthly include: - Kt/V (watch out for missing or out of range values)
- Long term catheter rate
- Missed or shortened treatments
- NHSN infection data
- Hospitalizations and readmissions
Tip:QIP penalties often happen because problems are identified too late.Create a simple QIP dashboard and review it during:
- Monthly QAPI meetings
- Medical director meetings
- Leadership huddles
4.
Monitor Measures Monthly—not Annually
Common data pitfalls that lead to penalties:
- Missing Kt/V reporting
- Incomplete EQRS entries
- Late or inaccurate NHSN reporting
- Failure to meet CAHPS survey requirements
Tip:
- Poor or missing data can score the same as poor performance.
- Assign clear data ownership for EQRS, NHSN, and CAHPS, and cross-check monthly.
5.
Protect Your Data Integrity
Many QIP measures are affected by day-to-day operational issues, such as:- Shortened treatments
- Missed treatments
- Inadequate blood flow rates
- Access problems
Tip:Track trends in:
- Treatment time delivered vs prescribed
- Missed treatments by the patient and the shift
- Chronic hypotension or access alarms
These issues often explain poor Kt/V and hospitalization scores.
6.
Focus on Treatment Consistency
Avoid CAHPS penalties by: - Reviewing survey results at QAPI
- Identifying top drivers of dissatisfaction (communication, staff responsiveness)
- Sharing results with staff
- Implementing at least one CAHPS-focused QI intervention annually
Tip:
- Patient experience directly impacts QIP scores.
- Even high-performing clinical facilities can lose points if CAHPS is ignored.
7.
Use CAHPS Results Proactively
9. Leverage Your ESRD Network
8. Document Your QI Work Strongly
Networks can:- Help interpret PSRs
- Assist with targeted QI strategies
- Email us at qsource-qidept@qsource.org
Surveyors and Networks expect to see:- QIP results reviewed
- Low-scoring measures addressed
- PIPs implemented and evaluated
Tip:If you cannot demonstrate QI tied to QIP performance, it may appear that the facility is not managing known risks, even if improvement is underway.
Tip:
- Reaching out early before scores are final can prevent long-term performance issues.
Take Action
Review your Performance Score Report carefully
Use QIP results to support QI work
Document questions for follow-up
Avoid QIP Penalties
Questions?
Learn more about ESRD QIP
ESRD QIP questions can be submitted via the QualityNet Q&A Tool.
Under Program, select “ESRD QIP – End-Stage Renal Disease-Quality Incentive Program.
Contact Your Network Staff to book a one on one technical assistance call to discuss your QIP score or work through quality improvement activities that may improve your QIP score.
Copyright © 2025 Qsource. All rights reserved. This material may not be reproduced, distributed, transmitted, cached, or otherwise used, except with the prior written permission of Qsource.
QIP measures
Care Coordination (30%)
Focuses on patient stability, transitions of care, and access to treatment options. Includes measures such as:
- Standardized Readmission Ratio (SRR)
- Standardized Hospitalization Ratio (SHR)
- Percentage of Prevalent Patients Waitlisted (PPPW)
- Clinical Depression Screening & Follow-Up
QIP measures
Patient & Family Engagement (15%)
Focuses on how patients experience care, communication, and support. Includes measures such as:
- In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Survey: Captures patient feedback on staff communication, responsiveness, and overall care experience
QIP measures
Clinical Care (35%)
Focuses on treatment effectiveness, outcomes, and clinical stability. Includes measures such as:
- Standardized Transfusion Ratio (STrR) reflects anemia management and complications
- Dialysis adequacy (Kt/V) ensures patients are receiving sufficient dialysis
- HD, PD, and pediatric variations
- Vascular Access Type: Long-Term Catheter Rate is an indicator of access quality and infection risk
QIP measures
Reporting (10%)
Evaluates whether the required clinical data is reported accurately and completely. Includes measures such as:
- Hypercalcemia (monitoring and reporting elevated calcium levels)
- Medication Reconciliation (ensuring medications are reviewed and documented)
- COVID-19 Vaccination among Healthcare Personnel
QIP measures
Safety (10%)
Focuses on reducing preventable harm and infection risk. Includes measures such as:
- Bloodstream infections (e.g., dialysis-related infections reported through NHSN)
Quality Incentive Program Overview_ESRD
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Transcript
Qsource ESRD Education Series
Quality Incentive Program (QIP) Overview
Learning Objectives
Qsource ESRD Network
ESRD Networks
ESRD Networks work in partnership with dialysis facilities to strengthen the systems that support patient care. Through shared data, clinical oversight, and targeted quality initiatives, ESRD Networks help teams focus improvement efforts where they have the greatest impact on outcomes that influence morbidity, mortality, and cost, including sepsis.
The Role of the ESRD Network
The ESRD Network partners with facilities throughout this process, serving as a convenor, organizer, motivator, and change agent. Networks support teams by:
Quality Improvement Initiatives
Medical Review Board Oversight
Emergency Preparedness & Response
Designs, supports, and monitors QI activities that target high-risk outcomes.
Provides clinical review, guidance, and accountability for quality and safety concerns.
Supports facilities and patients before, during, and after emergencies and disasters.
What Does the ESRD Network Do?
+ info
Patient Experience of Care
EQRS Data Management & Reporting
Community & Partner Collaboration
Promotes patient-centered care, engagement, and grievance resolution.
Convenes providers, patients, and community partners to spread best practices and accelerate improvement.
Ensures accurate data collection, reporting, and use for performance improvement.
+ info
Why the Quality Incentive Program (QIP) Matters
Why QIP Matters
What Impacts Your QIP Score
Rulemaking and Scoring Timeline
Rulemaking Process
Each year, CMS updates QIP through a federal rulemaking process. The general sequence is:
June- August
September- October
November
Start
June
CMS reviews comments and develops the final rule
CMS publishes the proposed rule in the Federal Register
HHS approves, and CMS publishes the final rule in the Federal Register
Public 60-day comment period
HHS reviews proposals
Why Timing Matters in QIP
QIP scoring is not immediate, it follows a multi-year cycle:
Year 2: Review & Finalize
Year 1: Data Collection
Year 3: Payment Impact
Your facility’s performance is captured across multiple systems (EQRS, NHSN, CAHPS, Medicare billing).
Final scores determine whether CMS applies a payment reduction.
You are given a limited 30-day window to review your performance scores, verify accuracy, and request corrections. Final Performance Score Reports are then released.
Example: Payment Year 2028 Measurement Period
What you do today impacts payment two years from now.
2026
2024
Performance Year or Calendar Year (CY)
Achievement Period
2028
2025
Payment Year
Improvement Period
Although we have used Payment Year 2028 as an example, please remember that depending on what Payment Year you are looking at, QIP Domains and Measures will differ. Refer to the website link below to utilize specific Payment Year Technical Specs outside of PY 2028. Refer to the website links below to utilize specific Payment Year Manuals and Technical Specs.
Link to ESRD QIP
QIP Domains and Measures
QIP Domains and Measures
Not all facilities will receive a Total Performance Score (TPS) due to low patient volume or a limited number of eligible cases. Importantly, the absence of a TPS does not equal poor performance. It often reflects data limitations rather than care quality.
QIP Domains and Measures PY 2028
The Total Performance Score is made up of five measure domains:
Reporting
Patient & Family Engagement
15%
10%
Safety
10%
30%
Care Coordination
35%
Clinical Care
Click on the plus signs to learn more about the individual measures in each domain.
Individual QIP Measures Removed From Previous Payment Years
As the ESRD QIP evolves, measures may be added, updated, or removed to reflect changing priorities in healthcare quality and reporting.Measures removed in recent Payment Years include:
These changes reflect ongoing efforts by the CMS to:
How Scoring Works
To get the most out of this section, locate your latest performance score report and refer to it as you review your facility’s scoring.
How Scoring Works
Measures are scored using achievement and improvement scoring models.
- Achievement scoring
- Compares your facility's performance on a measure during the performance period to the performance of all facilities nationally during the comparison period. (2 years prior).
- Improvement scoring
- Compares your facility's performance on a measure during the performance period to its own performance during the baseline period.
The facility receives the higher of the two scores for a measure. Measure scores generally range from 0 to 10.Improvement Score Methodology
Click on the information buttons for more.
Improvement Threshold
2026 Performance Period Rate
Benchmark
Improvement Score = 1-9
Improvement Score = 10
Improvement Score = 0
2026 Performance Period Rate
The orange line shows your facility’s current performance. Where it lands determines your score.
Improvement Score Example
Care Coordination Measure: Clinical Depression Screening and Follow-Up
Improvement Period Denominator
Performance Period Numerator
Performance Period Denominator
Improvement Period Numerator
Improvement Period Rate/Ratio
73
100
73.00%
87
92
Achievement Score
Performance Period Rate/Ratio
Achievement Threshold
Improvement Score
Benchmark
100%
94.57%
87.10%
Measure Weight (% of Domain)
Achievement Threshold
Measure Score
20.66%
Improvement Score Formula
If the facility's performance period rate falls within the improvement range, the improvement score will result between 1 and 9 using this formula:
Facility's Performance Period Rate Improvement Threshold
10 x
- 0.5
Benchmark Improvement Threshold
Improvement Score Example
94.57-73
Facility’s Performance Period Rate: 94.57% Improvement Threshold (2024 Rate): 73% Benchmark 100%
10 x
- 0.5
100-73
21.57
7.4
- 0.5
10 x
27
Final Measure Score = 7
Achievement Score Methodology
Hover over the information buttons for more.
2026 Performance Period Rate
Achievement Threshold
Benchmark
Achievement Benchmark Score
Below Achievement Threshold Score
Achievement Range Score
Achievement Score Formula
If the facility's performance period rate falls within the achievement range, the achievement score will result between 1 and 10 using this formula:
Facility's Performance Period Rate Achievement Threshold
9 x
+ 0.5
Benchmark Achievement Threshold
Achievement Score Example
Care Coordination Measure: Clinical Depression Screening and Follow-Up
Improvement Period Denominator
Performance Period Numerator
Performance Period Denominator
Improvement Period Numerator
Improvement Period Rate/Ratio
73
100
73.00%
87
92
Achievement Score
Performance Period Rate/Ratio
Achievement Threshold
Improvement Score
Benchmark
100%
94.57%
87.10%
Measure Weight (% of Domain)
Achievement Threshold
Measure Score
20.66%
Achievement Score Example
94.57-87.10
Facility's Performance Period Rate: 94.57%Achievement Threshold: 87.10%Benchmark: 100%
9 x
+ 0.5
100-87.10
7.47
5.7 (round to 6)
+ 0.5
9 x
12.9
Final Score = 6
Measure Score Determination
Care Coordination Measure: Clinical Depression Screening and Follow-Up
Improvement Period Denominator
Performance Period Numerator
Performance Period Denominator
Improvement Period Numerator
Improvement Period Rate/Ratio
73
100
73.00%
87
92
Achievement Score
Performance Period Rate/Ratio
Achievement Threshold
Improvement Score
Benchmark
100%
94.57%
87.10%
Measure Weight (% of Domain)
Achievement Threshold
Measure Score
20.66%
Weighted Measure Scores
QIP uses a weighted scoring system to reflect the relative importance of different measures and domains.Each measure is assigned a weight:
Example: Care Coordination Measure Domain PY 2028
Each of these four measures contributes equally to the Care Coordination domain score.
2 + 2 + 1.75 + 2.5
x 10 =
82.5 Care Coordination Domain Score
Total Performance Score PY 2028
TPS = 90.72 = 91%
Missing Measures and/or Domains
Payment Year Total Performance Scores and Payment Reductions
PY 2028 *Varies from year to year
Preview Period, Reports, and Certificates
QIP Preview Period
Facilities have an opportunity to review their scores during the QIP Preview Period, which usually lasts about 30 days in the summer. During this time, facilities can review calculations and submit inquiries if they believe errors occurred.
Submitting Inquiries
1.
Log into EQRS
Inquiries may be submitted for:
2.
Click "QIP Scores"
3.
Click "Period Inquiries"
4.
Follow the steps provided on the page
Performance Score Reports (PSRs) and Certificates (PSCs)
Click on the View/Download Reports tab
Step 1
Step 4
Log into EQRS
Reports are accessed through EQRS and require:- A HARP account
- A QIP user role
Enter/select your facility and any filtering options
Click on the nine dots in the upper left corner and select “QIP”
Step 2
Step 5
Click “Apply Filter” and then click on the hyperlinked report and download
Link: PY 2026 Guide to the UI
Enter/select your organization and click on “Go to QIP”
Step 3
Step 6
• Must remain posted until the next payment year PSC is available • Must be displayed in a prominent patient area • Must be displayed in English and Spanish
Certificates must be posted within 15 business days.
Sample Certificate
Sample Link
QIP and Quality Improvement
QIP tells you what the problem is. QI tells you how to fix it.
QIP Measures Reflect the Quality of Care Delivered
QIP measures are designed to evaluate real patient outcomes and care processes, such as:
- Dialysis adequacy (Kt/V)
- Infection rates
- Catheter use
- Readmissions and hospitalizations
- Patient experience (ICH CAHPS)
Quality improvement (QI) focuses on closing gaps between current performance and desired outcomes, which directly affects how a facility scores on these measures.QI provides the framework to:
Identify Root Causes
Analyze Trends
QI
Prioritize Risk Areas
Re-Measure Results
Implement Targeted Interventions
Example: Quality Improvement in Action
Examples:Low Kt/V scores
- QI project evaluates treatment time,
- blood flow rates,
- access issues,
- missed treatments
High catheter ratesQI Aligns Clinical, Operational, and Regulatory Goals
Strong QI programs help facilities:
- Improve patient outcomes
- Reduce variation in care
- Strengthen staff accountability
- Support compliance with CMS Conditions for Coverage
- Reduce financial risk from QIP payment reductions
QI allows leaders to explain not only results, but the actions taken to improve them.Surveyors and CMS Expect a QI Response to QIP Results
Facilities are expected to:
A lack of documented QI activity related to poor QIP performance may result in:
Quality Improvement is how facilities actively manage ESRD QIP performance. Without QI, QIP becomes reactive. With QI, QIP becomes a strategic tool to drive better care, stronger outcomes, and financial stability.
Preventing QIP Penalties
Not all measures carry the same weight.- While every measure plays a role in performance, some have a greater impact on outcomes.
- Take a strategic approach by prioritizing key measures and domains that drive meaningful, sustainable improvements at your facility.
Tip:
- Start each year by reviewing your current Performance Score Report (PSR) and circle:
- Measures scoring below national benchmarks
- Measures trending downward
These should become QI priorities, not just data points.Tips to Avoid QIP Penalties
Know Your QIP Measures and Prioritize Your Risks
1.
Best Practices:- Assign responsibility to a specific role (administrator, QI lead)
- Understand when reporting data deadlines are that affect certain measures.
- Review scores as soon as they’re released
- Use the preview period to:
- Validate data accuracy
- Submit corrections if needed
- Start improvement work immediately
Review Performance Score Reports Early and Often
2.
Facilities receive a Preview Performance Score Report before final scores are applied.
Tip:Waiting until the Final PSR limits your ability to respond and may lock in a penalty.
QIP scoring uses the higher of achievement or improvement.If your facility is below benchmarks:- You can still avoid penalties by showing measurable improvement
- Improvement scores are often easier to achieve with focused QI work
Tip:Every low-performing QIP measure should have:
3.
Use Quality Improvement to Capture Improvement Points
High-risk measures to monitor monthly include:- Kt/V (watch out for missing or out of range values)
- Long term catheter rate
- Missed or shortened treatments
- NHSN infection data
- Hospitalizations and readmissions
Tip:QIP penalties often happen because problems are identified too late.Create a simple QIP dashboard and review it during:
4.
Monitor Measures Monthly—not Annually
Common data pitfalls that lead to penalties:- Missing Kt/V reporting
- Incomplete EQRS entries
- Late or inaccurate NHSN reporting
- Failure to meet CAHPS survey requirements
Tip:
5.
Protect Your Data Integrity
Many QIP measures are affected by day-to-day operational issues, such as:- Shortened treatments
- Missed treatments
- Inadequate blood flow rates
- Access problems
Tip:Track trends in:
- Treatment time delivered vs prescribed
- Missed treatments by the patient and the shift
- Chronic hypotension or access alarms
These issues often explain poor Kt/V and hospitalization scores.6.
Focus on Treatment Consistency
Avoid CAHPS penalties by:- Reviewing survey results at QAPI
- Identifying top drivers of dissatisfaction (communication, staff responsiveness)
- Sharing results with staff
- Implementing at least one CAHPS-focused QI intervention annually
Tip:
7.
Use CAHPS Results Proactively
9. Leverage Your ESRD Network
8. Document Your QI Work Strongly
Networks can:- Help interpret PSRs
- Assist with targeted QI strategies
- Email us at qsource-qidept@qsource.org
Surveyors and Networks expect to see:- QIP results reviewed
- Low-scoring measures addressed
- PIPs implemented and evaluated
Tip:If you cannot demonstrate QI tied to QIP performance, it may appear that the facility is not managing known risks, even if improvement is underway.
Tip:
Take Action
Review your Performance Score Report carefully
Use QIP results to support QI work
Document questions for follow-up
Avoid QIP Penalties
Questions?
Learn more about ESRD QIP
ESRD QIP questions can be submitted via the QualityNet Q&A Tool.
Under Program, select “ESRD QIP – End-Stage Renal Disease-Quality Incentive Program.
Contact Your Network Staff to book a one on one technical assistance call to discuss your QIP score or work through quality improvement activities that may improve your QIP score.
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QIP measures
Care Coordination (30%)
Focuses on patient stability, transitions of care, and access to treatment options. Includes measures such as:
QIP measures
Patient & Family Engagement (15%)
Focuses on how patients experience care, communication, and support. Includes measures such as:
QIP measures
Clinical Care (35%)
Focuses on treatment effectiveness, outcomes, and clinical stability. Includes measures such as:
QIP measures
Reporting (10%)
Evaluates whether the required clinical data is reported accurately and completely. Includes measures such as:
QIP measures
Safety (10%)
Focuses on reducing preventable harm and infection risk. Includes measures such as: