The Data Map

One treatment’s data and everywhere it goes: the facility’s own loops—plan of care, QAPI—then the federal pipes into EQRS, NHSN, and the claims system, the processor that turns values into measure scores, and the same hemoglobin coming back regraded—a star rating, a QIP score, the report a surveyor reads before the visit.

TEXT ALTERNATIVE ↓

WIDE DRAWING · SCROLL SIDEWAYS TO READ IT ALL · THE FULL CONTENT IS ALSO IN WORDS BELOW

A station—where data rests

Data moves

The loop back—data comes back around

SOURCE 1 The ESRD Atlas dataset · 2 42 CFR Part 494 (§§ 494.20-494.180) · 3 CMS EQRS (End-Stage Renal Disease Quality Reporting System) · 4 CDC NHSN Dialysis Event Surveillance · 5 CMS-2728 / CMS-2744 / CMS-2746 · 6 UM-KECC / Dialysis Facility Reports · 7 ESRD Quality Incentive Program (CMS) · 8 42 CFR 413.178 · 9 CMS S&C 17-02

Reviewed as of 14 July 2026 Changelog

The drawing in words

The origin—the encounter. A treatment or monthly visit produces two things: labs drawn (Hgb, Kt/V, Ca/Phos, Alb) and clinical events (infections, hospitalizations, access procedures, vitals). [1 · 2]
Inside the facility, the first loop: labs feed the plan of care (IDT review), which drives prescription and protocol changes—and that loops back, changing the next treatment. [2]
The second facility loop: labs and events feed the QAPI dashboard (the facility’s self-grading), which feeds the QAPI meeting and its action plans, which loop back as practice changes. [2]
The federal reporting pipes. Labs go to EQRS: monthly clinical data. Events reach EQRS ONLY as admits and discharges plus the 2728, 2746, and 2744 forms. Infections go separately to NHSN—dialysis event surveillance, to CDC. Hospitalizations and access procedures reach the federal layer through the Medicare claim; vitals stay local. [1 · 3 · 4 · 5]
The processor: UM-KECC, at the University of Michigan, takes EQRS and claims and calculates the measures—SMR, SHR, STrR, and the QIP measure scores (claims/EQRS-based). [6]
NHSN-based measures are computed by CDC and delivered to the QIP directly—they never pass through UM-KECC. [1 · 4 · 6]
The outputs—the same hemoglobin, regraded. The measures become the QIP Total Performance Score, the Dialysis Facility Report, and the Care Compare star rating, which is public. EQRS and claims also feed the USRDS research registry. [1 · 6 · 7]
The consequence loops. The QIP score becomes a payment reduction of up to 2 percent—which loops back into the facility’s revenue and its operations. [1 · 8]
The Dialysis Facility Report feeds state survey and certification as presurvey prep (CMS S&C 17-02); EQRS and the QAPI dashboard feed survey too. Survey loops back as plans of correction. [2 · 9]
The measures feed the ESRD Network—quality improvement activity targeting, grievances—which loops back as improvement activities. [1]
The star rating feeds the patient choosing a facility. That loops back as census—and back to the start of the journey. [1]

BRACKETED NUMBERS TRACE EACH LINE TO THE SOURCE LIST BELOW · EVERY SOURCE IS HELD IN THE REFERENCES LEDGER WITH ITS LOCATOR, ITS LAST-CHECKED DATE, AND HOW IT WAS VERIFIED