2. -Abstraction Questions
Qsource Data Reporting Assistance Lesley Hays – Patient Care Improvement Manager
-Abstraction Back-up
-“Hot Lists”
-Deadlines
Debra Bratton, QI Specialist
-Abstraction Questions
-IQR/OQR
Stacy Jowers Dorris, QI Specialist
- NHSN
- HAI
Deborah Scott, Infection Prevention QI Specialist
-Data Submission
-QNet
-CART
Carol Griffin, Programmer

3. Discussion Points FY 2015 Validation Background
CLABSI, CAUTI, SSI – COLO/HYST
CLABSI/CAUTI Validation
Steps Involved
Responsibilities
Resources & Support
Deadlines

4. Background
FY 2015 Annual Payment Update (APU) Determination (FY 2015 Reference Checklist)
Submit Healthcare Associated Infections (HAI) data (
Hospitals collect and submit data to Centers for Disease Control and Prevention (CDC) through the National Healthcare Safety Network (NHSN).
Central Line-Associated Bloodstream Infection (CLABSI) data (ICU)
Catheter-Associated Urinary Tract Infection (CAUTI) data (ICU)
Surgical Site Infection (SSI) abdominal hysterectomy and colon surgery data (all)
Methicillin-resistant Staphylococcus aureus (MRSA) data (all)
Clostridium Difficile (C. Diff) data (all)
Healthcare Personnel Influenza Vaccination (all)
Hospitals with no ICU location and/or that performed 9 or fewer of any of the specified colon and abdominal hysterectomy procedures in the calendar year prior to the reporting year, can request an HAI exception for submission of CAUTI, CLABSI and SSI measures to fulfill the CMS Hospital IQR Program NHSN reporting requirement.

5. Background, cont.
400 Hospitals at random, with additional hospitals targeted
15 records selected per quarter for chart-abstracted clinical process of care measures (SCIP, HF, AMI, PN, ED/IMM)
12 records selected per quarter for HAI measures
Pass validation requirements
Receive a Confidence Interval of 75 percent or greater based on the combined chart audit validations for 4Q12 - 3Q13 discharges.
Submit HAI Validation Templates via QNet each quarter:
Validation Blood Culture Template
Validation Urine Culture Template
SSI COLO/HYST
Q4 2012, Q1 2013, Q2 2013, Q3 2013
400 hospitals with a supplemental selection of 200 hospitals based on targeting criteria. In addition, validation results for chart-abstracted clinical process of care and HAI measures will be separated.
Selected hospitals pass Validation requirements by receiving a Confidence Interval of 75 percent or greater based on the combined chart audit validations for 4Q12 through 3Q13 discharges.
New for FY Submit HAI Validation Templates: Hospitals submit a Validation Blood Culture Template and a Validation Urine Culture Template each quarter to facilitate the validation of the CLABSI and CAUTI measures.
FY2015 Validation – SSI – Colon and SSI – Abdominal Hysterectomy Validation:
• Identified through claims process -SSIs are reported more consistently in claims data than CLABSI and CAUTI.
• Candidate SSIs identification is different from the process for identifying candidate CLABSI and CAUTI.
• Claims data provide a resource for selecting candidate events for SSI using a methodology which limits burden to hospitals.
– SSI validation starts with 4Q12. These cases will be selected from claims data so there is nothing that the hospital needs to submit.

6. Validation Methodology
Basics for Candidate CLABSIs:
Final results for positive blood cultures for patients who were in the ICU when the blood culture was drawn
Presence of a central venous catheter (CVC) any time during the stay (including on admission)
Basics for CAUTIs:
Final results for all positive urine cultures with greater than or equal to 103 colony-forming units (CFUs)/ml
ICU admission during the hospital stay

7. Sample CLABSI Validation Steps - LEGEND
Hospital Iowa QIO (CMS Support Contractor) QIO Clinical Warehouse Centers for Disease Control and Prevention (CDC) Clinical Data Abstraction Center (CDAC)

8. Sample CLABSI Validation Steps
Identify candidate CLABSI events
Populate Blood Culture template
Submit Blood Culture template to CMS Contractor (Iowa QIO) via QNet by quarterly deadline
QNet Security Administrator
Iowa QIO loads all data from the Blood Culture template into large database
Positive blood cultures without the presence of a central venous catheter are removed from the database
(example – submit 60 +BCs on spreadsheet but only 10 have CVC answered Yes, then other 50 are removed)

9. Sample CLABSI Validation Steps, cont.
Iowa QIO randomly selects up to 4 candidate CLABSIs from the list remaining
(example – select 4 from the remaining 10)
Iowa QIO sends list of 4 candidate CLABSIs from each hospital to the QIO Clinical Warehouse and the CDC
CDC looks to see if hospital reported any of the 4 candidate CLABSIs via NHSN
QIO Clinical Warehouse adds the 4 candidate CLABSIs to the other 15 charts (HF, PN, AMI, SCIP, ED/IMM)

10. CLABSI Validation Steps, cont.
CDAC sends chart request for all medical records to hospital
Hospital produces copies of all requested medical records and submits to CDAC within 30-day timeframe
CDAC abstracts candidate CLABSI charts for each hospital to determine if the patient had infection related to a central line and sends results to Iowa QIO
CDC sends results of whether any of 4 CLABSI candidates were submitted via NHSN to Iowa QIO

11. CLABSI Validation Steps, cont.
Individual validation score is computed for each of the 4 candidate CLABSIs
CDC & CDAC report case CLABSI is 1/1
CDC & CDAC report different results causes case to return to Iowa QIO for review with CDAC
CDC & CDAC final determinations do not match, then case is 0/1
Individual validation scores will be combined with scores of other validation charts
Overall Validation Score <75% due to a CLABSI validation chart, hospital can appeal normally

12. HAI Validation TIPS Start Now! First Deadline is May 1st!
Hospital must continue to submit CLABSI/CAUTI/SSI data to NHSN
NHSN entry data submission deadline vs. CLABSI/CAUTI validation spreadsheets deadline
If hospital has a waiver in place, they are not required to submit the CLABSI/CAUTI template
If hospital has no positive blood cultures for a particular quarter, they are required to submit the CLABSI and CAUTI templates by the quarterly deadline

13. Deadlines Discharge Quarter HAI Template Due HAI Data Due Q4 2012
May 1, 2013
May 15, 2013
Includes Healthcare Personnel Vaccine
Q1 2013
August 1, 2013
August 15, 2013
Q2 2013
November 1, 2013
November 15, 2013
Q3 2013
February 1, 2013
February 15, 2013

14. Stacy Dorris, MBA, RHIA, CPHQ
QI Specialist