National Healthcare Safety Objectives for Ambulatory ...c.ymcdn.com/sites/ Healthcare Safety ... Reporting 101 for Ambulatory Surgery Centers A hli D d llAshlie Dowdell ... Slide sets

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National Healthcare Safety Network (NHSN) Reporting 101

for Ambulatory Surgery Centers

A hli D d llAshlie Dowdell

HAI Surveillance Coordinator

Wisconsin Division of Public Health

September 30, 2014

Provide an overview of NHSN.

Discuss federal reporting requirements for

Objectives

Protecting and promoting the health and safety of the people of Wisconsin 2

NHSN.

Review the NHSN enrollment process and the healthcare personnel influenza vaccination module.

History of NHSN

Developed and maintained by CDC.

Replaced three existing data collection systems with a launch in 2005.

Around 2009 was opened up to include hospitals of all sizes, dialysis, ambulatory surgery centers, etc.

Includes manual entry via secure web interface and electronic reporting through file import.


Reporting Options

Biovigilance Component

Patient Safety Component

Healthcare Personnel Safety Component

Hemovigilance Module

Device-Associated Module (CLABSI

Antimicrobial Use and Resistance Mod le

Blood and Body Fluid Exposure Mod le

LTC Component

HAI Module (UTI)

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Module (CLABSI, CAUTI, VAE, CLIP, DE)

Procedure-Associated Module (SSI, PPP)

MDRO/CDI Module

Module Module

Healthcare Personnel Influenza Vaccination Module

(UTI)

LabID Event Module (MDRO/CDI)

Prevention Process Measure Module (HH, GG)

Advantages

Free, web-based training.

Standardized surveillance protocols.

Reports built into the system for real time data analysis by Reports built into the system for real-time data analysis by users.

Risk-adjustment incorporated into reports.

Ability to share data securely with other organizations via the group function.

Gold standard for HAI data collection and reporting, used for federal and state reporting requirements.

Contributing to the national benchmarks, state aggregates. 5

Public Reporting

Used by 28 states; Washington, DC; and CMS for reporting infection events.

ASCs are mandated to report in at least 8 states.

More than 12,800 facilities currently use the system, including 390 ASCs.

6 Protecting and promoting the health and safety of the people of Wisconsin

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CMS Healthcare Facility HAI Reporting via NHSNCurrent and Proposed Requirements

Reporting Specifications HAI Event Reporting Starts

Acute Care Hospitals

CLABSICAUTISSI (COLO and HYST)MRSA Bacteremia LabID EventC. difficile LabID EventHCP Influenza Vaccination

2011, 2012, 2013

Outpatient Dialysis

IV antimicrobial startPositive blood cultureSigns of vascular access infectionHCP Influenza Vaccination (proposed)

2012

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HCP Influenza Vaccination (proposed)

Long-Term Acute Care Hospitals

CLABSICAUTIHCP Influenza Vaccination MRSA Bacteremia LabID EventC. difficile LabID EventVentilator-associated events

2012, 2014, 2015, 2016

Inpatient Rehabilitation Facilities

CAUTIHCP Influenza Vaccination MRSA Bacteremia LabID EventC. difficile LabID Event

2012

Ambulatory Surgery Centers HCP Influenza VaccinationOctober 2014 – proposed due date May 15, 2015

Inpatient Psychiatric Facilities HCP Influenza Vaccination 2015

NHSN ENROLLMENTFOR REPORTING HEALTHCARE PERSONNEL INFLUENZA VACCINATION


Enroll ASCs as Separate Facilities

“Each CMS-licensed ASC should enroll in NHSN as a separate facility (with a unique NHSN OrgID) even if they are owned by orNHSN OrgID) even if they are owned by or affiliated with a healthcare system or acute care hospital.”

CMS Operational Guidance for ASCs reporting flu data: http://www.cdc.gov/nhsn/PDFs/HCP/Operational-Guidance-ASC-HCP-Flu.pdf


Exception to Enrolling ASCs Separately

If the ASC:

Shares the exact same CMS Certification Number (CCN) as the hospital(CCN) as the hospital

AND

Is located on the hospital’s campus.

In that case, the ASC’s flu data are reported as part of the hospital’s totals per the Q&A session at the end of the 8/27/14 ASC flu module training (http://www2.cdc.gov/vaccines/ed/nhsn/).

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Checklist for Enrollment

Identify Facility Administrator

CDC training

Facility enrollment

Facility activation

Facility set up CDC training

Facility Administrator registration

SAMS


Facility set up

Monthly reporting plan

Summary data

Step 1: Identify Facility Administrator

Each facility can have only one.

Has the most administrative rights on the system.

Can appoint others with various administrative rights Can appoint others with various administrative rights as backup.

Typically the primary user of NHSN: Infection control coordinator, clinic manager, etc.

Only person who can join a group and confer rights.

Will enroll the facility in NHSN.

Can later reassign this role to another staff member. Protecting and promoting the health and safety of the people of Wisconsin 12

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Step 2: CDC Training

Slide sets to read through or an archived webcast to review.

Will take about 1 hour Will take about 1 hour.

Required before a facility administrator or user can enroll on the system. Registration form asks you for the date you completed training.

Discusses enrollment and set up process, data collection, numerators, denominators and data entry.

http://www.cdc.gov/nhsn/ambulatory-surgery/hcp-vaccination/index.html

http://www2.cdc.gov/vaccines/ed/nhsn/13 14http://www.cdc.gov/nhsn/ambulatory-surgery/hcp-vaccination/index.html

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http://www2.cdc.gov/vaccines/ed/nhsn/

Step 3: Facility Administrator Registration

Review CDC’s Facility Administrator Enrollment Guidefor details on enrollmentfor details on enrollment.– http://www.cdc.gov/nhsn/PDFs/Fa

cilityAdminEnrollmentGuideCurrent.pdf


FA Registration, Cont.

Read and accept the NHSN Rules of Behavior.

htt // h d /R i t ti F– http://nhsn.cdc.gov/RegistrationForm

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Complete registration information.

You will need to enter:– A facility identifier – use the

CCN (CMS Certification Number). 10 digits, “C” in the third position,

starts with “52” for WI facilities. Example: 52C0001070.

– Date you completed training.18

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You will receive an immediate confirmation email from NHSN with the subject “NHSN Facility Registration Submitted”Facility Registration Submitted”.

The second email will arrive within 24 hours from “Sams-no-reply (CDC)” to begin the SAMS registration process.


Step 4: Secure Access Management Services (SAMS)

Provides a platform for secure access to non-public CDC applications.

SAMS users need a password and “grid card” SAMS users need a password and grid card .– Will be prompted to choose a new password every 60 days.

Replaced the digital certificate access process. – Does not need to be renewed annually.

– Does not need to be downloaded to your computer.

– Those who already have a digital certificate will be migrated to SAMS.

Can be used on any number of computers.

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• Will need two forms of identification for the process.

• Commonly use driver’s license, passport, employee ID, etc.

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SAMS Grid Card

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Step 5: Facility Enrollment

Log into SAMS (https://sams.cdc.gov) using your password and grid card.

Select “NHSN Enrollment” Select NHSN Enrollment .

Submit required enrollment information. – Be sure to choose “AMB – SURG – Outpatient Surgery

Facility” as the facility type.

– Select the Healthcare Personnel Safety (HPS) Component check box. This is the section of NHSN used for reporting flu data.

– Facility surveys are not required to enroll in HPS to report flu data for CMS.

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Facility Enrollment, Cont.

Receive another email from CDC, subject line “NHSN Facility Enrollment Submitted”.

Print the Agreement to Participate and Consent form Print the Agreement to Participate and Consent form.

Have NHSN Facility Administrator and a clinic administrator (can be the medical director) sign the form.

Fax back to CDC.

CDC will notify you by email once they have activated your clinic on NHSN.


Congratulations, you’re live on NHSN!

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live on NHSN!

Enrolling Additional Facilities on Your Existing SAMS Account

Log into SAMS.

Click the “NHSN Enrollment” option and complete registration info for each additional facilityregistration info for each additional facility.

Make sure to use the same email address – that is how you will be the Facility Administrator for multiple ASCs using the same SAMS account.

If you do not see the “NHSN Enrollment” link, request it from the NHSN Help Desk ([email protected]).

Will need to sign/return a separate participation agreement for each ASC being enrolled.

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How Do I Access Multiple ASCs?


Fac: ASC A (ID 12345)

Fac: ASC B (ID 12346)

Fac: ASC C (ID 12347)

Step 6: Set up Facility/Add Users

Add other users to the facility account.

Recommend at least one other administrative user as a back-upas a back-up.

Can assign administrative (add/edit/delete data) or specific rights (only enter data, only view data, etc.).

Log into NHSN to add users and assign rights.

NHSN will automatically send new users instructions for SAMS registration.


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Step 7: Monthly Reporting Plan

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Monthly Reporting Plan, Cont.

For HPS, you only need to enter one monthly reporting plan for any month during the season (i e July 2014 June 2015)season (i.e., July 2014 – June 2015).

NHSN will automatically copy the remaining 11 plans for the season.

Must enter a plan before the system will allow you to enter flu data.

Triggers missing data alerts. Protecting and promoting the health and safety of the people of Wisconsin 32

Step 8: Summary Data

Flu summary > Add. Can be entered monthly or once at the end

of the season (e g after March 31)of the season (e.g., after March 31). System will overwrite the data when entered

monthly, so remember to keep adding it up as you go.

Contract personnel is an optional category for the CMS reporting requirements.


Alerts

Based on reporting plan entries.

Will display upon log in for every user in the facility.

Access via “Alerts” on the left side navigation bar too.


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Flu Survey

Optional at this time.

Will get a missing data alert about it.

Questions about vaccination campaign (e.g., cost to employees, types of venues where it was offered, reminder methods, documentation methods, etc.)


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FLU DATA REPORTING

Note: The NHSN Healthcare Personnel Influenza Vaccination module protocol and frequently asked questions are available at http://www.cdc.gov/nhsn/ambulatory-surgery/hcp-vaccination/index.html.


Healthcare Personnel (HCP) Influenza Vaccination

Module is designed to ensure influenza vaccination coverage is:

C i t t ti ithi th f ilit– Consistent over time within the facility.

– Comparable across facilities.

Summary level data.

ASCs will start with the 2014-2015 flu season.

Data only needs to be entered once at the end of the flu season.


HCP Categories

Employees

Licensed independent practitioners (LIP)

Adult students/trainees and volunteers

Contract personnel


Employees

Receive a direct paycheck from the reporting facility (i.e., on the facility’s payroll), regardless of clinical responsibility or patientregardless of clinical responsibility or patient contact.

Includes LIPs if they receive a paycheck from the facility.


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Licensed Independent Practitioners

Physicians (MD, DO), advanced practice nurses (NPs, nurse midwives, clinical nurse specialists, nurse anesthetists), and physician assistants.anesthetists), and physician assistants.

Affiliated with the reporting facility, but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact.

Post-residency fellows are also included in this category if they are not on the facility’s payroll.


Trainees and Volunteers

Includes medical, nursing, or other health professional students, interns, medical residents or volunteers aged 18 or olderresidents, or volunteers aged 18 or older.

Affiliated with the healthcare facility, but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact.


Contract Personnel

Optional at this time.

Those who provide care treatment or

Examples include: – Nurses.

– Surgical technicians.care, treatment, or services at the facility through a contract who do not fall into any of the above-mentioned denominator categories.

Surgical technicians.

– IT staff.

– Construction workers.

– Admitting staff.


1 Working Day

Physically present in the building.

Includes those who join after October 1 or leave before March 31, are on extended leave, etc.

Working any number of hours in the day = 1 working day.

Includes full-time and part-time staff.

Regardless of patient contact. Protecting and promoting the health and safety of the people of Wisconsin 46

Numerator

Healthcare workers in the denominator categories who from the time the vaccine became available (e g August or September)became available (e.g., August or September) through March 31 of the following year fall into one of the vaccination, contraindication or declination categories.


Numerator Categories

Received an influenza vaccination administered at the reporting healthcare facility.

Received the vaccination elsewhere.

Had a medical contraindication.

Was offered but declined vaccination.

Had an unknown vaccination status or did not meet any of the other numerator categories.


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Numerator Notes

Vaccination elsewhere needs to be documented in writing (paper or email).

D t d t b f th d i i t i id– Does not need to be from the administering provider.

– Can be an email from the healthcare worker indicating the vaccine was received.

Any other exemptions (e.g., religious, personal conviction) granted by the facility should be included in the “declined” category.


Numerator Notes, Cont.

Included contraindications: – Severe allergic reaction (e.g., anaphylaxis) after a

previous vaccine dose or to a vaccine componentprevious vaccine dose or to a vaccine component, including egg protein.

– History of Guillain-Barre Syndrome within 6 weeks after a previous influenza vaccination.

Any other medical reasons should fall into the “declined” numerator category.

Do not need to have written documentation for the contraindication. 50

Numerator Notes, Cont.

HCP with a medical contraindication to live attenuated influenza vaccine other than the two listed should be offered the inactivatedtwo listed should be offered the inactivated influenza vaccine.

The numerator categories are mutually exclusive, so all of the numerator categories should add up to the total listed for the denominator in that health care worker group.


Frequently Asked Questions

Staff can be counted for more than one ASC if they are physically present in each for > 1 working day.

Physician owners go into the employee category Physician owners go into the employee category.

Acceptable forms of documentation for vaccination outside the facility include:

– Signed statement/form or email from the HCP.

– Note/receipt/vaccination card from the vaccinating entity.

Vendors demonstrating products, delivery personnel, etc. would not fall into the required categories of healthcare personnel, so their vaccination status does not need to be tracked for this module. 52

Frequently Asked Questions, Cont.

Dentists, dental assistants, surgical techs, etc. (anyone not explicitly listed in the LIP definition) are not included in the LIP category. If they are notnot included in the LIP category. If they are not employees, then they would be in the contractor category.

If the ASC shares the same CMS Certification Number (CCN) as the hospital and is located on the hospital’s campus, the ASC’s flu data are reported as part of the hospital totals.


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Questions about HCP Influenza Vaccination?


Next Steps

Review NHSN training.

Enroll in NHSN.

Evaluate ability to capture each category of healthcare personnel.

Determine if there are any additional processes/documentation methods needed before you start administering flu vaccine.

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www.cdc.gov/nhsn

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Questions?

Ashlie DowdellHAI Surveillance CoordinatorWisconsin Division of Public HealthWisconsin Division of Public [email protected]


Documents

National Healthcare Safety Objectives for Ambulatory ...c.ymcdn.com/sites/ Healthcare Safety ... Reporting 101 for Ambulatory Surgery Centers A hli D d llAshlie Dowdell ... Slide sets