EQRS News Flash: Facility Commitment to Health Equity Dashboard Available in EQRS

Facility Commitment to Health Equity Dashboard available in EQRS 

July 25, 2024 


On July 18, 2024, the Centers for Medicare & Medicaid Services (CMS) released the Health Equity Attestation Dashboard in the End-Stage Renal Disease (ESRD) Quality Reporting System (EQRS). 
This new dashboard provides ESRD Networks and dialysis organizations with real-time information and visualization on attestations submitted throughout the calendar year for the ESRD Facility Commitment to Health Equity (FCHE) reporting measure.
This measure will be added to the ESRD Quality Incentive Program (QIP) beginning in payment year (PY) 2026. Corporate level and Network level users can utilize this dashboard to access an aggregate summary of FCHE attestations submitted by facilities in their purview for any given year.
Further information on this measure is available at:
hhttps://www.cms.gov/files/document/cy-2024-technical-measure-specifications.pdf.
This EQRS News Flash provides corporate and Network users with instructions on how to access and view the new dashboard feature.

Accessing the Health Equity Attestation Dashboard 

To access the Health Equity Attestation Dashboard, log in to the Patient Registry and select Reports Dashboard in the navigation bar. 

Click the Health Equity Attestation Dashboard option to display the dashboard. 

Dashboard Overview 

The top of the Health Equity Attestation Dashboard contains information on the data sources used and refresh frequency (how often the data are updated) for the tables and figures displayed on the page. Additionally, the top of the dashboard contains information on instructions for using the dashboard. 



Figure 1 – Data Source and Refresh Frequency Information 

Figure 2 – Instructions for Using the Dashboard 

Once you select the Annual Reporting Period (Figure 3), the dashboard displays total number of facilities in the user’s purview (Total Facilities), number of facilities attested (Attested Facilities), number of facilities with missing attestations (Missing), and the percent of facilities that have attested (Attestation Rate) for the annual reporting period selected (Figure 4).  



Figure 3 – Annual Reporting Period for FCHE Attestation 

Note: Users can only select a single year. 



Figure 4 – Health Equity Attestation Summary Table 

A “speedometer” graph appears next to the Health Equity Attestation summary table. This graph provides a quick visual synopsis of the percentage of facilities with submitted attestations among the user’s purview during the selected year (Figure 5). 



Figure 5 – Percentage of Facilities with Submitted Attestations 

Health Equity Attestation – Network and Corporate-level Summary 

A summary of attestations by each of the five FCHE Domains displays below the summary table and speedometer graph (Figure 6). The table indicates the annual reporting period selected (Time Period), how many facilities within the user’s purview (Total Facilities), submitted attestations (Attested Facilities), number of facilities within the user’s purview that have not submitted attestations (Missing), percentage of facilities with a submitted attestation (Attestation Rate), and number of facilities that attested yes to all (Yes to All), did not attest to any (No to All), or attested to some (Yes to Some) of the elements within each of the five domains.  

Figure 6 – Health Equity Attestation Details by Domain 

For Network users, the Dashboard also provides a summary of attestation details by Domain and EDI organization (Figure 7). 



Figure 7 – Health Equity Attestation Details by Domain and EDI Organization 

Health Equity Attestation – Facility Summary 

The Health Equity Attestation – Facility Summary section of the dashboard provides a table containing the attestation information for each individual element within the Domain. Users may apply filters to this table by using the Filter by option above the summary table (Figure 8).  Users may filter by facility the CMS Certification Number (CCN), facility state, and Attestation Submitted status.  

Figure 8 – Filter Options for Facility Summary Table

The CCN filter allows users to filter by a single CCN. Type a CCN in the box directly below Facility CCN and press the Enter key to initiate the search. The Facility Summary Table will display data matching your search. 

The Facility State filter (Figure 9) allows users to filter the Facility Summary Table by facility state. The system will default to the facility states within the user’s purview. Users may check the Select all option to view all states, or search for individual states and click on the box next to the state. The Facility Summary Table will display data matching your search. 



Figure 9 – Facility State Filter 

The Attestation Submitted filter allows users to filter the Facility Summary Table by Health Equity Attestation status (Figure 10). To limit the Facility Summary Table to facilities that submitted attestations, check the Yes box. Similarly, to limit to those facilities that have not submitted the attestations, check the No box. If you do not wish to filter by attestation status, check the Select All box.  



Figure 10 – Health Equity Attestation Submitted Filter 

Please note that facilities with Attestation Submitted = ‘Yes’ indicates the facility confirmed and submitted their attestations (Figure 11).  



Figure 11 – Confirm and Submit Attestation  

View the attestation results (‘Yes’/’No’) for each individual Domain element in the table to the right of the Attestation Submitted column to determine whether the facility indicated they have completed each of the elements in the Domain. To receive full points for the ESRD QIP FCHE reporting measure, each column must indicate ‘Yes.’ 

In addition to the Facility CCN, Facility State, and Attestation Submitted status, the Facility Summary table displays the annual reporting period (Time Period), responses to each individual element of a Domain, with the Domain specified after the element in parentheses, Network, EDI Name, EDI Facility ID, and Facility ID (Figure 12). 



Figure 12 – Facility Summary Attestation Details 

Health Equity Attestation Insights by Domain 

The Health Equity Attestation figures contain “pie” charts that summarize the results of the attestations for each of the elements within the Domain. An example of Domain 1 is displayed in Figure 13. A color key is located to the right of the graph that defines the three colors in the pie chart. The definition of the domain and the individual elements display to the left of the pie chart. 

Figure 13 – Domain 1 Results 

For details regarding the ESRD QIP FCHE reporting measure, please review Section 2.24 of the ESRD Measures Manual.  

For assistance with EQRS technical issues, please contact the Center for Clinical Standards and Quality (CCSQ) Service Center. The CCSQ Service Center is open Monday-Friday 8 a.m. to 8 p.m. Eastern Time and can be reached via phone at 866-288-8912, email at qnetsupport-esrd@cms.hhs.gov or online at the CCSQ Support Center



For assistance with general EQRS and ESRD QIP questions, please contact the ESRD QIP Team via the QualityNet Q&A Tool