USING THE WEBEX Q&A FEATURE All lines are placed on mute to block out background noises. However, you can send in questions to the panelists via the Q&A button. Follow the directions below to use the Q&A button: 1. Move your mouse over the WebEx Navigation Panel at the top of your screen. The menu will drop-down. 2. Click the Q&A icon. The Q&A panel will display on your screen. 3. Click the drop-down arrow next to Ask: and select All Panelists. Type your question, and click the Send button. Your question will be viewed and addressed by a Subject Matter Expert. 6/7/2016 1
IPFQR Program NHSN Enrollment and HCP Measure Data Submission Processes Elizabeth Kalayil, MPH Public Health Analyst Centers for Disease Control and Prevention (CDC) Amy Webb, MPH Public Health Analyst, CDC Evette Robinson, MPH Project Lead, Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program Value, Incentives, and Quality Reporting (VIQR) Outreach and Education Support Contractor (SC) June 7, 2016
Purpose During this presentation participants will receive: A brief description of the Influenza Vaccination Among Healthcare Personnel (HCP) Measure, as a requirement of the IPFQR Program Step-by-step instructions on how to complete the National Healthcare Safety Network (NHSN) enrollment and the HCP measure data submission processes Answers to questions posed to speakers during this live forum related to NHSN enrollment and the HCP Measure 6/7/2016 3
Learning Objectives By the end of the presentation, attendees will be able to: Identify resources to complete NHSN enrollment and enter HCP measure data Discuss concerns pertaining to the NHSN enrollment HCP measure data entry processes 6/7/2016 4
Acronyms APU Annual Payment Update CCN CMS Certification Number CMS Centers for Medicare & Medicaid Services FR Final Rule FY Fiscal Year HPS Healthcare Personnel Safety IPF Inpatient Psychiatric Facility PPS Prospective Payment System SAMS Secure Access Management Services TBD To Be Determined 6/7/2016 5
IPFQR Program NHSN Enrollment and HCP Measure Data Submission Processes OVERVIEW OF THE HCP MEASURE REQUIREMENT IN THE IPFQR PROGRAM 6/7/2016 6
Overview of the HCP Measure The HCP measure was finalized in the FY 2015 IPF PPS Final Rule, published August 6, 2014 The IPF reporting of HCP influenza vaccination summary data to NHSN will begin for the 2015-2016 influenza season, from October 1, 2015, to March 31, 2016, with a reporting deadline of May 15, 2016. Although the collection period for this measure extends into the first quarter of the following calendar year, this measure data will be included with other measures that will be required for FY 2017 payment determination. (79 FR 45969) A full description of the measure is found on pages 45968 45970 of the FY 2015 IPF PPS Final Rule. 6/7/2016 7
Overview of the HCP Measure The HCP measure is designed to: Ensure that reporting of influenza vaccination coverage among healthcare personnel data is consistent over time within a single healthcare facility and comparable across facilities Allow staff members in healthcare facilities to use the Influenza Vaccination Summary to monitor influenza vaccination percentages among HCP The HCP measure is relevant to IPFs because: CMS finalized the inclusion of the HCP measure into the IPFQR Program, In the FY 2015 IPF PPS Final Rule IPFs must meet this and all other requirements of the IPFQR Program starting in the FY 2017 payment determination year, or else be subject to a 2% reduction to APU 6/7/2016 8
Overview of the HCP Measure 6/7/2016 Data are collected on denominator and numerator categories Denominator categories: o HCP must be physically present in the facility for at least one working day between October 1 through March 31 o Full-time and part-time HCP are included Employee HCP: Staff on facility payroll Non-employee HCP: Licensed independent practitioners (physicians, advanced practice nurses, and physician assistants) Non-employee HCP: Adult students/trainees and volunteers Numerator categories: o Influenza vaccinations, medical contraindications, declinations, and unknown status Facilities are required to report all numerator categories for the three denominator categories 9
IPFQR Program NHSN Enrollment and HCP Measure Data Submission Processes NHSN ENROLLMENT INSTRUCTIONS 6/7/2016 10
Key Roles in NHSN Facility Administrator (one per facility) Enrolls the facility with NHSN Activates additional components for a facility Adds/edits/deletes rights to facility data, users, and users access Nominates/joins groups for data sharing Re-assigns the role of Facility Administrator to another user Users Rights are determined by Facility Administrator and may include data viewing, entry, and analysis Administrative rights may be given 6/7/2016 11
Getting Started in the HPS Component Enrolling in NHSN Facilities that are currently not participating in NHSN and wish to participate must enroll their facility in NHSN. Newly enrolled facilities are advised to enter a CCN effective date of January 1, 2016, or earlier to ensure that any data submitted is sent to CMS. Please visit http://www.cdc.gov/nhsn/enrollment/index.html for more information regarding the enrollment process. Adding an IPF location IPF units located within acute care/critical access facilities must be added as a unit within the already enrolled acute care/critical access hospital. Activating the HPS Component Facilities that are already enrolled in NHSN and wish to participate in the HPS Component must activate the component within NHSN. 6/7/2016 12
Getting Started in the HPS Component for Free-Standing IPFs Is your free-standing IPF enrolled in NHSN? NO YES Enrollment Activation Choose an NHSN Facility Administrator NHSN Facility Administrator activates the HPS Component Five-Step Enrollment Process Are you unsure of your facility s status with NHSN? If so, email nhsn@cdc.gov Facility Administrator adds Administrative User 6/7/2016 13
Getting Started in the HPS Component for IPF Units Is your IPF unit enrolled in NHSN? NO YES Enrollment Activation Choose an NHSN Facility Administrator Five-Step Enrollment Process NHSN Facility Administrator activates the HPS Component Facility Administrator adds Administrative User Adding a Location Confirm that the IPF unit has been added as a location within your NHSN facility. If it has not been added, follow the steps using this link: http://www.cdc.gov/nhsn/pdfs/mrsa-cdi/ipf-locations.pdf Are you unsure of your facility s status with NHSN? If so, email nhsn@cdc.gov 6/7/2016 14
Activating the HPS Component For Existing NHSN Facilities Log in, as the facility administrator, to SAMS at https://nhsn2.cdc.gov/nhsn/ Select NHSN Reporting. From the Home Page, click Facility, then Add/Edit Component. Check the box next to Healthcare Personnel Safety. Add the HPS Component Primary Contact by entering the name, phone, email, and address of the person to be contacted with CDC/NHSN updates or questions about the HPS Component. 6/7/2016 15
Activating the HPS Component for Existing NHSN Facilities Facility Administrator adds HPS Component Primary Contact as a user within the NHSN facility 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 E-mail Address Must be an active/correct address for the user Facility Administrator adds other users or new HPS Component Primary Contact Facility Administrator should ensure that at least one HPS Component user has administrative rights 6/7/2016 16
User Rights Any user with administrative rights can add users After saving the new user information, the Edit User Rights screen will appear Please be sure to confer the proper rights to users 6/7/2016 17
New Users to NHSN Receive an invitation to register with SAMS New users will automatically receive an invitation to SAMS after being added as a user to the facility Complete and submit identity verification documents to CDC Access NHSN using SAMS credentials Information about the process can be found at: http://www.cdc.gov/nhsn/sams/about-sams.html 6/7/2016 18
IPFQR Program NHSN Enrollment and HCP Measure Data Submission Processes HCP MEASURE REPORTING REQUIREMENTS 6/7/2016 19
Denominator Reporting Requirement: Inclusions Required Employees (staff on facility payroll) Licensed Independent Practitioners Adult students/trainees and volunteers Optional Other contract personnel 6/7/2016 20
Numerator Reporting Requirement: Inclusions Numerator reporting requirement inclusions for the HCP measure consist of HCP who: Received an influenza vaccination at the reporting healthcare facility since the influenza vaccine became available this season Provided a written report or documentation of receiving an influenza vaccination outside the reporting healthcare facility since the influenza vaccine became available this season Have a medical contraindication to the influenza vaccine Declined to receive the influenza vaccine Have an unknown vaccination status (or criteria not met for above-mentioned categories) 6/7/2016 21
IPFQR Program NHSN Enrollment and HCP Measure Data Submission Processes HCP MEASURE DATA SUBMISSION INSTRUCTIONS 6/7/2016 22
Required and Optional Reporting Forms After enrolling in NHSN and/or activating the HPS Component and adding users: Complete Required Forms HCP Safety Monthly Reporting Plan HCP Influenza Vaccination Summary Form Complete Optional Form Seasonal Survey on Influenza Vaccination Programs for HCP 6/7/2016 23
Log into SAMS You can access the activity home page by clicking https://nhsn2.cdc.gov/nhsn/ Enter your SAMS user name and password Enter SAMS grid card numbers For assistance with SAMS, contact the SAMS Help Desk at 1-877- 681-2901 or samshelp@cdc.gov 6/7/2016 24
NHSN Home Page 6/7/2016 25
Navigating NHSN Use NHSN buttons to navigate (do not use Web browser buttons) View facility name, user, and component in use at the top of the screen 6/7/2016 26
HPS Component Home Page 6/7/2016 26
HCP Safety Monthly Reporting Plan Form Collects data on which modules and months the facility plans to participate Users should select Influenza Vaccination as appropriate The plan is automatically updated with this information for the entire NHSN-defined influenza season (July 1 to June 30) The user will not need to add any reporting plans after the initial monthly plan has been added for that influenza season. 6/7/2016 28
Monthly Plan View for IPF Units Click Reporting Plan then Add Select correct month and year from dropdown menus Check appropriate box next to Influenza Vaccination Summary for reporting hospital data or IPF unit(s) data 6/7/2016 29
Monthly Plan View for Free-standing IPFs Click Reporting Plan then Add Select correct month and year from dropdown menus Check box next to Influenza Vaccination Summary 6/7/2016 30
Saving the Monthly Plan Click Save when finished 6/7/2016 31
HCP Influenza Vaccination Summary Form Collects summary influenza vaccination counts among HCP HCP influenza summary reporting in NHSN consists of a single data entry screen per influenza season Each time a user enters updated data for a particular influenza season: All previously entered data for that season will be overwritten A new modified date will be auto-filled by the system 6/7/2016 32
HCP Influenza Vaccination Summary Form NHSN data entry screen mirrors the HCP Influenza Vaccination Summary Form Denominator (Question 1) Numerator (Questions 2-6) 6/7/2016 33
Table of Instructions The Table of Instructions outlines the instructions and definitions for each data field in the NHSN module The Instructions for the HCP Influenza Vaccination Summary Form are located in the HCP Influenza Vaccination Summary Protocol: http://www.cdc.gov/nhsn/forms/57-214-hcp-influenza-vaccination- Summary-Form- TOI-.pdf 6/7/2016 34
HCP Influenza Vaccination Summary Data Click Flu Summary then Add Influenza Vaccination Summary Data appears as the only option Click Continue 6/7/2016 35
Summary Report for Hospitals with IPF Units Influenza and Seasonal are the default choices for vaccination type and influenza subtype Select appropriate flu season in drop-down box (e.g., 2015-2016) Select the appropriate location for reporting hospital or IPF unit(s) data 6/7/2016 36
Summary Report for Free-standing IPFs Influenza and Seasonal are the default choices for vaccination type and influenza subtype Select appropriate flu season in drop-down box (e.g., 2015-2016) 6/7/2016 37
HCP Influenza Vaccination Summary Data Entry Screen The asterisks indicate required columns that must be completed Use the Custom Fields function for data that a facility would like to collect and analyze consistently Use the Comments box to enter any additional information, such as side notes 6/7/2016 38
HCP Influenza Vaccination Summary Data Entry Screen: Custom Fields Click Facility then Customize Forms Complete all mandatory fields Enter label and select type and status Click Save when finished 6/7/2016 39
HCP Influenza Vaccination Summary Data Entry Screen: Custom Fields A message will appear at the top of the screen indicating that the Custom Fields have been updated The Custom Fields will now appear on the data entry screen 6/7/2016 40
Editing HCP Influenza Vaccination Summary Data For each update of the data after the initial entry, a message will indicate that a record of the summary data already exists The Date Last Modified shows when the data were last entered 6/7/2016 41
Editing HCP Influenza Vaccination Summary Data Click Edit to modify existing data 6/7/2016 42
Saving HCP Influenza Vaccination Summary Data Click Save to save the updated data 6/7/2016 43
Saving HCP Influenza Vaccination Summary Data A message confirming that data were saved should appear at the top of the screen 6/7/2016 44
IPFQR Program NHSN Enrollment and HCP Measure Data Submission Processes HELPFUL RESOURCES 6/7/2016 45
CDC NHSN Resources IPF NHSN Enrollment/Location Mapping Detailed Checklist for IPFs: http://www.cdc.gov/nhsn/pdfs/gen-support/ipf-enrollmentchecklist.pdf NHSN Enrollment for Free-standing IPFs: http://www.cdc.gov/nhsn/ipfs/enroll.html IPFs within Acute Care and Critical Access Hospitals o Ensure that the main hospital has completed the NHSN Enrollment process: http://www.cdc.gov/nhsn/acute-carehospital/enroll.html o Complete NHSN Location Mapping for IPFs within Hospitals: http://www.cdc.gov/nhsn/pdfs/mrsa-cdi/ipf-locations.pdf 6/7/2016 46
CDC NHSN Resources HCP Measure Data Submission Training Slides for IPFs: http://www.cdc.gov/nhsn/pdfs/training/vaccination/hcp-fluvax-summary-reporting-ipf-training.pdf Training, Protocols, Data Collection forms, CMS Supporting Materials, FAQs: http://www.cdc.gov/nhsn/ipfs/vaccination/index.html NHSN User Support Email nhsn@cdc.gov for additional information and include IPF NHSN Enrollment or IPF HCP Measure Data Submission in the subject line. Be sure to include the name and CCN of the facility in the 6/7/2016 body of the email. 47
CMS Resources IPFQR Program Webinars held April 16, 2015, and February 18, 2016 QualityNet: Inpatient Psychiatric Facilities > Webinars/Calls 2015 and Webinars/Calls 2016 Quality Reporting Center: Inpatient > IPFQR Program > Archived Events Webinar materials include: Presentation Slides Recorded Webinar Presentation Transcript Questions and Answers Transcript 6/7/2016 48
IPFQR Program NHSN Enrollment and HCP Measure Data Submission Processes QUESTIONS 6/7/2016 49
Frequently Asked Questions Question When trying to enter data in NHSN, why do I receive an error message stating that a plan does not exist with Influenza Vaccination Summary for Flu Season entered? Which month and year should I select on the monthly reporting plan for the HCP Vaccination Module? Response You are receiving this message because you have not added a monthly reporting plan. Note that a monthly reporting plan must be added in order to report the Influenza Vaccination Summary data. To add this plan, click Reporting Plan and then Add on the NHSN navigation bar after logging in to the Healthcare Personnel Safety Component. Next, select a month and year from the dropdown menus; you can select any month and year during the current influenza season. Then, check the box next to Influenza Vaccination Summary under the Healthcare Personnel Vaccination Module and click Save." You can then proceed to enter your influenza vaccination summary data. You can select any month within the current influenza season. Therefore, it is fine if you enter a single summary data report for one month (e.g., March 2015). Unlike the other NHSN components and modules, when Influenza Vaccination Summary is selected on one reporting plan, the information is automatically updated on all reporting plans for the entire influenza season as defined by NHSN (which is July 1 to June 30). Therefore, adding other reporting plans after the initial plan has been added for that influenza season is not necessary. 6/7/2016 50
Frequently Asked Questions Question Do I need to report data each month? Response HCP influenza vaccination summary reporting in NHSN consists of a single data entry screen per influenza season, and this can be entered at any time during the influenza season, which is defined by NHSN as July 1 to June 30. Therefore, monthly reporting in NHSN is not required, and entering a single influenza vaccination summary report at the end of the reporting period for the influenza season will meet the minimum data requirements for NHSN participation. However, CDC/NHSN encourages that HCP influenza vaccination summary counts be updated on a monthly basis so they can be used at the facility level to impact influenza vaccination activities. For the purposes of fulfilling CMS quality measurement reporting requirements, the summary report will only be submitted once to CMS. 6/7/2016 51
Open Forum 6/7/2016 52