Presentation on theme: "HCP Influenza ~ NHSN Reporting Requirements for the Massachusetts Department of Public Health & CMS Eileen McHale, BSN, MDPH, HAI Coordinator Denise Selfridge,"— Presentation transcript:
HCP Influenza ~ NHSN Reporting Requirements for the Massachusetts Department of Public Health & CMS Eileen McHale, BSN, MDPH, HAI Coordinator Denise Selfridge, CPHQ, Performance Improvement Advisor, Masspro Nora McElroy, MDPH, Epidemiologist/Data Manager for NHSN March 13, 2013
Slide 2 Presentation Overview Provide the context and background for the implementation of the National HealthCare Safety Network (NHSN) Healthcare Personnel (HCP) Influenza Vaccination Measure Review MDPH and CMS Reporting Deadlines Describe the NHSN Technical Specifications
Slide 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!
Slide 4 MDPH Regulatory Background % 71% 84% Licensure regulations acute care hospital HAI reporting Results of HCP Vaccination Reporting to the Lehman Center Flu Vaccination a Condition of Licensure in all Facilities MDPH Requires Acute Care Hospitals to Report Data to NHSN (CMS Quality Data Reporting) MDPH Sets Performance Goals
Slide 5 Why NHSN? A 2006 study showed substantial lack of uniformity in the way U.S. hospitals measure Healthcare Personnel (HCP) vaccination rates –Difficult to compare rates over time or among facilities In 2008 the National Quality Forum issued a provisional endorsement to a CDC sponsored standardized measure –Measure designed to ensure reported data are comparable across facilities
Slide 6 Why NHSN? Measure was pilot tested by CDC during the influenza season –234 facilities National Quality Forum fully endorsed the revised pilot tested measure on 5/2/12
Slide 7 CMS REQUIREMENT The Centers for Medicare & Medicaid Services (CMS) added HCP influenza vaccination reporting using this measure to its quality reporting programs –Acute 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
Slide 8 MDPH Requirement To 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.
Slide 9 MDPH Data Requirements Deadline for data submission to NHSN : –APRIL 15, 2013 Hospitals must submit: –Monthly Reporting Plan –Seasonal Influenza Summary Survey –Summary data for vaccinations administered when the vaccine becomes available through March 31, 2013.
Slide 10 MDPH Performance Goal Minimum 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 ).
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-Mar13
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 year If 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 Categories HCP must be physically present in the facility for at least 30 days between October 1 and March All hospital paid employees 2.Non-employee HCP: Licensed independent practitioners (Physicians, advanced practice nurses, and physician assistants) 3.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 Categories Influenza vaccinations given Immunizations 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 Contraindications Severe allergic reaction after previous dose, allergy to vaccine components or history of Guillain-Barre Syndrome Verbal statement is adequate. Declinations Verbal statement is adequate. Unknown 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.
18 Now select Healthcare Personnel Safety
19 HCW Monthly Reporting Plan
20 Seasonal Influenza Summary Survey Select Surveys from left Complete Seasonal Survey Click Save
21 Seasonal Influenza Summary Form
22 Seasonal Influenza Summary Form
23 Click Users on the navigation bar, then click Add Complete Add User screen mandatory fields User ID – created by the facility First Name Last Name Address – Must be an active/correct address for the user Adding Users
24 Adding Users
26 Entering Flu Summary Data
28 HCP Summary and Event Data Entry
29 Getting your facility data to the State To get you facility data to the state you must confer rights to the Massachusetts Group.
30 Getting your facility data to the State
31 Getting your facility data to the State
32 Getting your facility data to the State
/ 2013 Data Submission Deadlines To meet the Massachusetts data submission requirements All HCP data must be entered and rights conferred to the state group no later than April 15, 2013 To meet the CMS data submission requirements All HCP data must be entered and HCP report plan completed no later than May 15, 2013