Presentation on theme: "Eileen McHale, BSN, MDPH, HAI Coordinator"— Presentation transcript:
1 HCP Influenza ~ NHSN Reporting Requirements for the Massachusetts Department of Public Health & CMS Eileen McHale, BSN, MDPH, HAI CoordinatorDenise Selfridge, CPHQ, Performance Improvement Advisor, MassproNora McElroy, MDPH, Epidemiologist/Data Manager for NHSNMarch 13, 2013
2 Presentation Overview Provide the context and background for the implementation of the National HealthCare Safety Network (NHSN) Healthcare Personnel (HCP) Influenza Vaccination MeasureReview MDPH and CMS Reporting DeadlinesDescribe the NHSN Technical Specifications
3 Why Healthcare Personnel Vaccination? Healthcare personnel (HCP) may be an important source of transmission of the influenza virus.The most effective method of preventing influenza and its potentially serious complications is annual immunization.As well as protecting patients, vaccination of HCP has been shown to reduce absenteeism among healthy workers, resulting in financial savings to healthcare facilities.Despite the strong recommendation of major public health agencies, professional societies and healthcare organizations for annual, universal immunization of healthcare workers against influenza, overall rates of immunization among healthcare workers has remained low.Identified as a measure of patient safety and is the right thing to do!
4 MDPH Regulatory Background MDPH Requires Acute Care Hospitals to Report Data to NHSN (CMS Quality Data Reporting)2013201284%MDPH Sets Performance Goals2011Flu Vaccination a Condition of Licensure in all Facilities71%2010Results of HCP Vaccination Reporting to the Lehman Center200968.1%Licensure regulations acute care hospital HAI reporting2008
5 Why NHSN?A 2006 study showed substantial lack of uniformity in the way U.S. hospitals measure Healthcare Personnel (HCP) vaccination ratesDifficult to compare rates over time or among facilitiesIn 2008 the National Quality Forum issued a provisional endorsement to a CDC sponsored standardized measureMeasure designed to ensure reported data are comparable across facilities
6 Measure was pilot tested by CDC during the 2010-2011 influenza season Why NHSN?Measure was pilot tested by CDC during the influenza season234 facilitiesNational Quality Forum fully endorsed the revised pilot tested measure on 5/2/12
7 CMS REQUIREMENTThe Centers for Medicare & Medicaid Services (CMS) added HCP influenza vaccination reporting using this measure to its quality reporting programsAcute care hospitals began reporting data on January 1, 2013 (for the influenza season)season will not be reported on Hospital Compare.Acute care hospitals must enter data into NHSN by May 15, 2013, for data to be shared with CMS for the influenza season
8 MDPH RequirementTo be consistent with the CMS requirement and avoid unnecessary duplicate reporting, MDPH required all acute care hospitals to report healthcare personnel (HCP) influenza vaccination data to the NHSN beginning with the influenza season.
9 MDPH Data Requirements Deadline for data submission to NHSN:APRIL 15, 2013Hospitals must submit:Monthly Reporting PlanSeasonal Influenza Summary SurveySummary data for vaccinations administered when the vaccine becomes available through March 31, 2013.
10 MDPH Performance GoalMinimum performance goal for acute care hospital healthcare employee vaccination rates for the influenza season.Statewide, the MDPH expects that a 90% influenza vaccination coverage rate will be reached for all acute care hospital employees, with no facility reporting a rate less than 86% (two percentage points above the Massachusetts acute care hospital average reported rate of 84% in ).
11 CDC NHSN HCP Influenza Summary Reporting Denise Selfridge, CPHQ March 13, 2013 This material was prepared by Masspro, the Medicare Quality Improvement Organization for Massachusetts, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily represent CMS policy.10-ma-ptcare hai-hcp-flu-webinar-Mar1311
12 Required CMS Quality Data Reporting To comply with the CMS Quality Data Reporting, beginning January 2013 CMS requires acute care hospital to report Healthcare Personnel Influenza Vaccination by summary method using the CDC NHSN database.The data range is October 1, 2012 –through March 31, 2013, entering data from January 1, 2013 forward is mandatory, entering data that includes October through December is optional, this yearIf your facility data is not complete and present by May 15, 2013 you will fail submission. And be non-compliant with reporting requirements.
13 Healthcare Personnel (HCP) Influenza Vaccination Summary Method Denominator CategoriesHCP must be physically present in the facility for at least 30 days between October 1 and March 31.All hospital paid employeesNon-employee HCP: Licensed independent practitioners(Physicians, advanced practice nurses, and physician assistants)Non-employee HCP: Adult students, trainees and volunteers (over the age of 18 years)Optional ~ Not currently required but available for use.Non-employee HCP: Other Contract personnel
14 Healthcare Personnel (HCP) Influenza Vaccination Summary Method continued Numerator CategoriesInfluenza vaccinations givenImmunizations given when the vaccine becomes available as soon as August are counted.Vaccines received outside of facility can be qualified with documentation. Verbal statement is not adequate.Medical ContraindicationsSevere allergic reaction after previous dose, allergy to vaccine components or history of Guillain-Barre SyndromeVerbal statement is adequate.DeclinationsUnknown Status
15 Healthcare Personnel (HCP) Influenza Vaccination Summary Method continued The reporting season is October 1 through March 31 A facility need only enter the data once to capture the entire reporting period. Each time data is entered during a reporting period it will over write previous entries. Immunizations given when the vaccine becomes available as early as August are counted. Reporting is required as of the January 1, 2013 and through March 31, 2013 for season 2012/2013.
23 Adding Users Click “Users” on the navigation bar, then click “Add” Complete “Add User” screen mandatory fieldsUser ID – created by the facilityFirst NameLast NameAddress – Must be an active/correct address for the user
33 2012/ 2013 Data Submission Deadlines To meet the Massachusetts data submission requirementsAll HCP data must be entered and rights conferred to the state group no later thanApril 15, 2013To meet the CMS data submission requirementsAll HCP data must be entered and HCP report plan completed no later thanMay 15, 2013