Texas Healthcare Safety Network Facility Users Training Welcome to the Texas Healthcare Safety Network or “Texan” Facility Users Training Presentation. Jessica Presley is the TxHSN Database manager and Jennifer Vinyard is the Epidemiologist for HAI reporting. Jessica Presley, MPH HAI Database Manager 512.776.6488 Jennifer Vinyard, MPH, CIC Epidemiologist 512.776.3773

Objectives Overview of HAI Reporting Review TxHSN & the reporting timeline Updating Contact Info Reviewing Facility Errors Report NHSN Missing/Incomplete List Tutorial Reviewing Data Display Report Standardized Infection Ratio Explanation Making Comments Today we will briefly go over the Texas Healthcare Associated Infections Reporting requirements. Then we will review TxHSN and how it is used at different times over the reporting timeline. We will review how Facility Users can update designated contact information, review their facility-specific errors report, and how to review and make comments on the Data Display report that will be made visible to the public.

Link to Legislation & Reporting Resources: www.HAITexas.org HAI reporting updates Reporting Resources/Tools Sign up for email updates Email questions A great resource for finding Texas HAI reporting resources is our website… www.HAITexas.org. Here you can find links to applicable legislation, any reporting news or updates, an FAQ sheet and other guides that will help you through the reporting process. I strongly recommend you check out this site, especially if you’re not very familiar with the reporting requirements. Also, you can sign up for email updates… that way, when we add or change things on the website, you’ll be notified of the change, instead of you having to log in every day to hunt for additions or changes to the website.

Texas Reporting http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf PHASE HAI Facility Type/Unit Start Date 1st CLABSI PEDIATRIC and ADULT General Hospital ICUs October 1, 2011 KPRO and related SSIs ADULT General Hospitals and ASCs VSHN and related SSIs PEDIATRIC General Hospitals 2nd (in addition to 1st phase) HPRO and related SSIs January 1, 2012 CBGB and related SSIs CBGC and related SSIs CARD and related SSIs HTP and related SSIs 3rd (in addition to 2nd phase) VHYS and related SSIs January 1, 2013 HYST and related SSIs COLO and related SSIs PVBY and related SSIs CEA and related SSIs AAA and related SSIs FUSN and related SSIs RFUSN and related SSIs LAM and related SSIs General Hospitals (excluding comprehensive rehabilitation facilities) and Ambulatory Surgery Centers are required to report CLABSIs and certain SSIs for Mandatory State Reporting. These HAIs are being phased in: The first phase of reporting included CLABSIs that occur on or after Oct 1, 2011 in ICUs of General Hospitals, SSIs related to knee arthroplasties performed on or after Oct 1, 2011 for adult hospitals and ASCs and SSIs related to V-shunts for Pedi Hospitals. The 2nd phase in period starts in 2012 and will add, for Adult Hospitals and ASCs – Hip prosthesis and CABGs and for Pediatric Hospitals, Cardiac Procedures (including heart transplant) The final, 3rd phase for Adult Gen Hosp and ASCs adds, Hysterectomies (vag and abd), Colons and vascular procedures. For Pedi Hosp, it’s Spinal surgeries. Slide 6 shows the HAI phase in by NHSN procedure category. For more information on what the abbreviations are, please see NHSN SSI Manual linked here.

HAI Reporting to CMS via NHSN – Current and Proposed Requirements DRAFT (11/23/2011) HAI Event Facility Type Reporting Start Date CLABSI Adult, Pediatric, & Neonatal ICUs (Acute Care ) January 2011 CAUTI January 2012 SSI I.V. antimicrobial start Dialysis Facilities Positive blood culture Signs of vascular access infection Long Term Care Hospitals * October 2012 Inpatient Rehabilitation Facilities MRSA Bacteremia LabID Event Acute Care Hospitals January 2013 C. difficile LabID Event HCW Influenza Vaccination ASCs October 2014 SSI (future proposal) Outpatient Surgery/ASCs TBD * Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN I included this slide showing the proposed CMS reporting requirements (as of Nov 2011) to illustrate the differences between CMS reporting through the National Healthcare Safety Network or NHSN and Texas mandatory reporting through NHSN. Both these tables are available to view on our website (www.HAITexas.org) under the Reporting link. 5

Reporting SSIs: CMS vs Texas All SSIs are to be reported to NHSN Superficial Deep Organ Space Texas will display a composite SIR that includes all 3 SSI types. CMS will display a SIR for only Deep and Organ Space. In order to use NHSN, all facilities must enter any Superficial, Deep or Organ Space Surgical Site Infections (SSIs) that occur due to surgical procedures performed at their facility. However, another big difference between CMS reporting and Texas reporting is that CMS will only display an SSI SIR or Standardized Infection Ratio that includes only Deep and Organ Space infections. Texas will display a composite SIR that includes all 3 types of SSIs.

Intro to Texas Healthcare Safety Network (TxHSN) Next we will discuss how the Texas Healthcare Safety Network or TxHSN (pronounced Texan) will be used in the Texas reporting process.

HAI Reporting Overview In order to help coordinate & simplify the communication process, we’ve developed a communication portal of sorts. It is called the Texas Healthcare Safety Network or TxHSN. It is a web-based application that designated facility contacts will be able to log into to view reports and make comments about their data. This diagram shows how the general reporting process will work. Basically, each healthcare facility will log on to NHSN (the National Healthcare Safety Network) to enter all HAI data. DSHS will have rights to pull your data from NHSN. The data that DSHS gets from NHSN will then be stored in TxHSN and facility-specific reports will be generated there. TxHSN will email the designated contacts to notify them that their reports are ready to view in TxHSN. The facility contacts will then log into TxHSN and run reports and comment on data as they see fit. Texas Healthcare - Safety Network - Alerts regarding data & reports View reports & make comments 8

Log in information Primary & Secondary Facility Contacts will receive a secure email from TxHSN ~May. Link to TxHSN Username/Password General TxHSN Instructions Back in September 2011, each facility should have received a letter addressed to your CEO from Dr. Lakey, our Commissioner, to notify you that the first phase of reporting began October 1, 2011. Those facilities that were required to report (those that had an ICU and/or performed any of the applicable Texas reportable procedures) should have returned a form indicating they were required to report and provide us with up to two designated contacts. Those facilities that do not have an ICU nor perform any reportable procedures were instructed to return a form that indicated they were not required to report. Those facilities that did not send back a form were assumed to be required to report and the facility’s NHSN Facility Administrator was designated the facility contact. These designated contacts are the individuals responsible for communicating with DSHS, reviewing reports and making comments on the data display reports that will be available to the public. Again, if no contact was given, then we’ll use your facility’s NHSN Facility Administrator as the official contact. The CEO letters will be sent out annually, to keep our records up to date with the most current contact information. Is it EXTREMELY important that the contact information we have for your facility is correct. If either of these contacts need to be changed, please contact us as soon as possible so we can update your facility’s user accounts appropriately.

Application: Always select Main Logon to TxHSN: Your username = First letter of your first name + your full last name + Last 3 digits of your NHSN ID 1st time password Once you receive your username and password emails, you will be able to login to TxHSN. Follow the link on the email. It will bring you to the TxHSN website. Enter your login name. This will be the first letter of your first name followed by your last name and the last 3 digits of your NHSN facility ID. NOTE: THIS IS CASE SENSITIVE SO ALL USERNAMES WILL BE IN LOWERCASE. Then enter the first-time password assigned to you (again, this is case sensitive). The Application should default to Main. Then click the Login Button. Application: Always select Main 10

Password Security 8 Characters At least one number At least 3 letters At least 2 symbol Expires every 60 days Do not share your username/password Remember: Comments can be posted to your public data display reports Can reset your password if you forget Here are the password requirements. The new password must be at least 8 characters, include 3 letters, 1 number and 1 symbol and will need to be updated every 60 days. And please do not share your username or password with others. I updated this slide 5/1/12 JP

Main Page Once you log into TxHSN, you will be taken to the Main Page, shown here. On the dark gray toolbar, you will see a little Magnifying Glass. This allows you to search for your facility record. Since your facility record is the only record you have access to, you will only need to do this once. After you find your facility record, it will display in the Recent Records box below and you can access your facility record by double clicking on your Facility Record Number. And again, because you only have access to one record (your own), only one record will ever show in this box. The Activity Summary Table on the Right of your screen shows you the total number of records imported for the state of Texas. Under the Resources & Support section, you have a link to log into NHSN, a link to the HAITexas website as well as contact information for the Texas Department of State Health Services. One other important thing to note: do not use your internet browser’s back button. Often times it will not work and instead kick you out of TxHSN altogether.

Recently opened records Main Page: What’s what Find your facility (1st Log in Only) Click here to log out Recently opened records You will only have access to your facility. Therefore, the only record listed here will be yours.

Find Your Facility 1st time login: You will need to find your facility record the first time you log in. To do this, click the magnifying glass icon on the toolbar to open the Search window. Now that we know where everything is, let’s look up your facility. Click on the Magnifying Glass icon in the dark gray toolbar.

Find Your Facility 1. From the dropdown box for ‘Record Type’ select ‘Facility’ A Search Record window will appear. Select ‘Facility’ from the Record Type dropdown box. Then click the ‘Search’ button on the bottom left. 2. Then click ‘Search’ button.

Find Your Facility Your facility will show up in the Search Results box. Double click on your facility name to open record. Your Facility will list in the Search Results table on the right side of the window. Double click on your facility name to open the record. If this is not your facility’s name, please contact us right away so we can identify the problem.

Facility Dashboard: What’s what Click ‘Unload Record’ to return to the Main Page This is how facilities will access their reports Click these links to view your reports Double ‘Facility Comment Tracking’ to review/make comments When you open your facility record, it will take you to your Facility Dashboard. Because you cannot use your browser’s back button, to get back to the Main page, click the ‘Unload Record’ link on the right side of the dark gray tool bar. Under Record Summary, you will see 3 Facility Links. These are your facility-specific data reports: 2 data display reports (one brief and one detailed version) and the Facility Errors Report. In the Question Package Section, you will see two modules: The Facility Information Module and the Facility Comment Tracking module. The Facility Information Module will allow you to view the contact information for your facility and change some of the contact information for your primary and secondary contact. The Facility Comment Tracking module will allow you to review and make comments on the data display report that will be made available for the public to view. Double ‘Facility Information’ to view/update contact information 17

Updating Contact Info To update contact information for your Primary and Secondary Contact: Click on “Facility Information” from your Facility Dashboard. Then scroll to the bottom section. You may change Title, Phone/Fax and Mail Code for these contacts. Don’t forget to click “Save” after you make changes NOTE: If contact name or email change, please contact DSHS (usernames will be affected). This is a screenshot showing the primary contact information from the Facility Information module. Please note, that you will be able to change your contacts titles and phone numbers, but will not be able to change the email or name of the contacts. In order to do this, you must contact DSHS at the email address given. Cancel or Save to return to Facility Dashboard.

Facility Dashboard: Return to Main Page Click ‘Unload Record’ to return to the Main Page This is how facilities will access their reports To return to the Main page, click “Unload Record” 19

Using TxHSN for HAI Reporting: Errors Report Next we will review the Errors Report

Texas’ Reporting Time Line Reporting Quarter Q1: Jan 1 – Mar 31 H1: Jan 1 – June 30 Q3: July 1 – Sept 30 H2: July 1 – Dec 31 Data submission deadline (facility enters data into NHSN) According to NHSN rules: ~within 30 days of end of reporting month Departmental data reconciliation (Data from NHSN –emails facility contacts ~15th) 1-Jun 1-Sep 1-Dec 1-Mar Facility data corrections due (in NHSN) 30-Jun 30-Sep 31-Dec 31-Mar DSHS data summary to facilities (DSHS sends email to contacts) NA 15-Oct 15-Apr Facility comment period (Facility enters comments into TxHSN) 30-Oct 30-Apr DSHS review of comments 15-Nov 15-May Public posting of summary (with approved comments) For Texas reporting, the year is broken down into 4 time periods: Q1, H1, Q3, H2. For each of these time periods, you will have an opportunity to check and correct data in NHSN. Data is due within 30 days of the end of the reporting month, in compliance with NHSN rules of behavior. DSHS will then pull the data from NHSN on June 1st, Sept 1st, December 1st and March 1st. 15 days after the Departmental Data Reconcilliation, the primary and secondary facility contacts will receive an email notification from TxHSN saying that the Facility Errors Report is ready to review and to correct errors in NHSN within 15 days. On the 16th day, DSHS will re-pull the final data from NHSN. 21

1st email: Review Errors Report 1’ & 2’ Contacts will receive email Contacts may logon to TxHSN Click on link to run Facility-specific Errors Report Correct any data errors in NHSN Re-run Errors Report after deadline Based on the timeline, Q1 data will be pulled from NHSN by June 1st. On around the 15th of the month, we will send out an email, via TxHSN to the facility contacts to notify them that they can log into TxHSN and review their data errors report. Facilities will then have until June 30th to log into NHSN to correct errors, as needed.

Errors Descriptions Error Type Explanation Month with plan and no denominator Please enter denominator data into NHSN if applicable. Month with 0 rate (no infections entered) Please verify and correct in NHSN if applicable. This alert is intended as a check-point for your facility and does not indicate non-compliance. Month with plan and denominator = 0 Please verify and correct in NHSN if applicable. This alert is intended as a check-point and does not indicate non-compliance. Month with denominator and no plan Please enter a monthly reporting plan in NHSN for this event type if you are required to report this HAI to Texas. Month with plan/event and denom = 0 Please verify and correct in NHSN. Month with events and no denom/plan Incomplete record Please enter correct data in NHSN for the procedure number shown. The following would cause a procedure record to be incomplete: Missing one or more of the risk factors as defined in Appendix D of the NHSN October 2010: Special Edition Newsletter Procedure duration is <5 minutes or >IQR5 (see Appendix E of NHSN Newsletter) Patient's age at procedure is >= 109 years Wound Class = 'U' (Unknown) Approach for FUSN or RFUSN = 'N' Spinal Level for FUSN = 'N' Inpatient surgery performed at outpatient surgery center Please change Outpatient = 'N' to 'Y' for the NHSN procedure number shown. Length of stay in ICU/NICU prior to CLABSI > 60 days Errors Descriptions This slide shows a table of the errors that can be identified. The first 7 listed are the same as the errors found on the NHSN Missing and Incomplete List. The last two are just a couple additional checks to make sure your data is accurate.

Facility Dashboard: What’s what This is how facilities will access their reports From the Facility Dashboard, click on the link for Facility Errors Report 24

Log in and View Errors Report You can sort the report by month, error type or record ID. Then click Run Report.

Example of Facility Errors Report This is an example of a Facility Errors Report. At the top of the page, you can see the number of records we have broken down by type of record. The next section has a list of Errors… the first few are based on the Incomplete/Missing Data List, but there are a few extra things we’ve flagged… for example, there will be an error listed for inpatient procedures performed at an ASC.

Export Errors Report to Excel You can also export the report into an EXCEL file by clicking the Export Results button instead of the Run Report Button. This will bring up the report in an Excel spreadsheet.

Using TxHSN for HAI Reporting: Data Display Report Now we will discuss the Data Display Report

Texas’ Reporting Time Line Reporting Quarter Q1: Jan 1 – Mar 31 H1: Jan 1 – June 30 Q3: July 1 – Sept 30 H2: July 1 – Dec 31 Data submission deadline (facility enters data into NHSN) According to NHSN rules: ~within 30 days of end of reporting month Departmental data reconciliation (Data from NHSN –emails facility contacts ~15th) 1-Jun 1-Sep 1-Dec 1-Mar Facility data corrections due (in NHSN) 30-Jun 30-Sep 31-Dec 31-Mar DSHS data summary to facilities (DSHS sends email to contacts) NA 15-Oct 15-Apr Facility comment period (Facility enters comments into TxHSN) 30-Oct 30-Apr DSHS review of comments 15-Nov 15-May Public posting of summary (with approved comments) Twice a year, for each half year, you will receive an email after the facility errors report notification that tells you that your Data Display Report is ready to view in TxHSN and that you have 15 days to submit a comment to be posted along with your data. 29

2nd Email: Review Data Display & Make Comments 1’ & 2’ Contacts will receive email Contacts may logon to TxHSN Link to Run Preliminary Data Display Report Brief – SIR and Interpretation Extended – Numerator, Denominator, Expected # Infections, SIR, SIR Interpretation Make comments on Data Display Report For the data display report, there are two different versions: One is a brief, simple report that shows the SIR and an interpretation. The extended version shows the numerator (or # of infections), the denominator, the expected/predicted number of infections (based on national averages), along with the SIR and Interpretation. After the comment deadline, DSHS will have 15 days to approve any submitted comments. Comments will not be approved if there is inappropriate language, references to another healthcare facility, references data from a different reporting time period or are submitted after the comment deadline. All approved comments will be displayed on both versions of the report for the public.

Log in and View Data Display Report Click on either the Extended Facility Data Display Report or the Brief Facility Data Display Report. For this example, we will be looking at the Extended report.

Example: Data Display Report (Extended Version) This is a an example of a hospital’s Extended Data Display Report with Facility Comments. Please note the Report Current As of Date. Because we are analyzing a snapshot of your data, any changes that you make to the data in NHSN after this date will not be reflected in the report. Please note the Statistical Interpretation column. This value is based on the SIR and the p-value. If the P-Value (which is not shown) is greater than 0.05, the facility’s infection experience is about the same as the national experience. If the P-Value is less than 0.05 and the SIR is less than 1, the facility is better than the national experience. If the p-value is less than 0.05 and the SIR is greater than 1, the facility is worse than the national experience. These interpretations are shown visually using a star system… the more stars, the better the facility. Please note that if the Predicted Number of Infections is less than 1, then NHSN will not calculate a SIR and therefore the interpretation is that there is not enough data to interpret/calculate a difference.

SIR Calculation SIR = Standardized Infection Ratio Compares the actual number of HAIs with the predicted number, based on the baseline U.S. experience (i.e., standard population), Adjusted for risk factors SIR > 1 = Higher rate than expected (i.e. Worse than national experience) SIR < 1 = Lower rate than expected (i.e. Better than national experience) P-value <= 0.05 indicates significance If not significant, then the rate is about as expected (i.e. About the same as national experience) The SIR or Standardized Infection Ratio is a number that compares the number of HAIs that occur in a facility to a predicted number of infections (based on the US data and adjusted for risk factors). If the SIR is > 1, a facility is worse than the national experience. If the SIR is < 1, a facility is better than the national experience. The p-value determines whether the SIR is significantly different from the national experience. If it does not indicate significance (by being greater than or equal to 0.05), then the facility is about the same as the national experience.

Using TxHSN for HAI Reporting: Submitting Comments The last thing we are going to discuss is how to submit a comment.

Double Click “Facility Comment Tracking” from your Facility Dashboard Make a Comment Double Click “Facility Comment Tracking” from your Facility Dashboard To do this, log into TxHSN and click on the Facility Comment Tracking module.

Make a Comment Type your comment here. (Character limit of 1250) Enter your comment in the blank space provided. You will be given up to 1250 characters. You can click anywhere outside the box after entering your comment. This will refresh the webpage and additional fields will display below your comment. 2. Then click anywhere outside the box. TxHSN will then refresh and display additional fields below your comment.

Submit Comment 1. From the drop down box, select ‘Yes’ The “Submit comment to DSHS for review” question will default to No. A comment will not be reviewed by DSHS until this is saved as Yes. Once you do select Yes, the Comment submitted by field will populate with your name. You will be able to return to this page to check on the status of your comment. 2. Click ‘Save’ button at the bottom

DSHS Will Review Comments Comments will not be approved if it: Contains inappropriate language Refers to another healthcare facility Refers data from a different reporting time period (other than the current) Are submitted after the comment deadline Comments will not be approved for the following reasons: If you use inappropriate language Refer to another healthcare facility Refer to another time period

DSHS Will Review Comments DSHS will have 15 days to review comments. Check back regularly to review your comment status. If your comment is not approved and it is before the 15 day deadline for DSHS to review comments, you may enter a FINAL comment. Therefore, best to make comments ASAP after the Data Display Report is available for viewing. DSHS will review comments as soon as we can get to them. If you comment is not approved and it is not past the deadline, you will get one more chance to submit a comment. Because this process is time sensitive, we recommend you submit your comment as soon after you get the notification as possible so that you will have time to submit a second comment if the first is not approved.

Example of Extended Data Display Report – With Comments This is a an example of a hospital’s Extended Data Display Report with Facility Comments. This comment will display on both the Extended and the Brief versions of this report. Approved comments will display here on both Data Display Report versions.

Public HAI Website UNDER CONSTRUCTION: On www.HAITexas.org, there will be a link to the website where the Data Display Reports will be available for the public to view. We will post a link to the public website where the facility specific data display reports will be available. This link will be on our HAITexas website under the “Data” link.

Contact Information General Reporting Questions HAITexas@dshs.state.tx.us Reporting/NHSN Questions: Jennifer 512.776.3773 Jennifer.Vinyard@dshs.state.tx.us User Names/TxHSN Questions: Jessica 512.776.6488 Jessica.Presley@dshs.state.tx.us