1. Tamara Hoxworth, PhD Colorado Dept. of Public Health & Environment Manager, Health Facility Infection Surveillance Unit 1

2. Reporting, Reporting #$@&%*! I Can’t Take Anymore!! 2

3. Objectives 1. Explain Colorado’s HCW Flu Immunization reporting law and HAI Disclosure Statute. 2. Present rationale for state reporting requirements. 3. Review State and Federal HCW Flu immunization reporting requirements. 4. Review State HAI reporting requirements. 5. Explain where and how to report data required for these reporting laws. 6. Provide resources and contact information for assistance. 3

4. Health Facility Infection Surveillance Unit 1. Colorado Health Care Worker (HCW) Influenza Immunization Rule – applies to all of you Monitor facilities reporting HCW into NHSN or State Portal Ensure public reporting through an annual report (this year will be 1 st facility specific report of immunization rates) 2. Colorado HAI Disclosure/Reporting Law – some of you Monitor facilities reporting HAI into National Healthcare Safety Network Ensure public HAI reporting by publishing Annual HAI Disclosure Report (facility specific HAI rates) for legislature and general public (have copies) Conduct validation studies to ensure data accuracy and completeness Coordinate HAI advisory committee - has a dedicated position for ASC rep 4

5. ASC Reporting Requirements Colorado State Requirements HCW Flu Immunization Reporting Rule (all of you) HAI Disclosure Statute (surgical site infections-SSI) – some of you Federal (CMS) Requirements If you participate in ASC Quality Reporting (medicare pts), you report HCW Flu Vaccinations into NHSN Other quality measures like burns, falls, etc. that we don’t collect- Telligen 5

6. Why Report SSI and HCW Flu Immunizations? SSIs cause HARM Substantial cause of morbidity, prolonged hospitalization, death, cost burden on individuals & health system, reduced quality of life. Important to track surgeries and related infections to ensure health care providers focus on SSI and identify areas needing intervention. Surveillance of SSI with feedback to surgeons has shown to be a critical component of strategies to reduce SSI. Flu causes HARM Even more of a threat in health care settings, esp. for vulnerable populations. Easily spread by droplets from coughing and sneezing. People can be contagious a day before symptoms and go to work unaware they’re getting sick and contagious. Patients have right to know that their health care provider has taken precautions to protect them from health care associated infections. 6

7. Colorado HCW Influenza Immunization Rule Board of Health Rule approved Feb 15, 2012 Developed with extensive stakeholder input Applies only to facilities LICENSED by CDPHE: Hospitals, Long Term Care, ASC Other facilities: Assisted Living, Home Health, Dialysis Does not apply to entities NOT licensed by CDPHE: Outpatient physician clinics, doctor’s offices, dental offices, and chiropractor’s offices 7

8. Definition of a Health Care Worker Anyone working in a licensed healthcare entity who has potential for exposure to: patients residents consumers of the healthcare entity infectious materials, including body substances contaminated medical supplies and equipment contaminated environmental surfaces contaminated air 8

9. Who is a Health Care Worker? This definition includes, but is not limited to: physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees, contractual personnel, home care personnel, and persons not directly involved in patient care (e.g., admin, clerical, dietary, house- keeping, laundry, security, maintenance, billing and chaplains) and for NHSN reporters only, volunteers 9

10. Rule Requirements All health care entities licensed by CDPHE are required to: Have defined procedures to prevent the spread of influenza from unvaccinated workers Keep track of the number of employees vaccinated Maintain supporting documentation for a period of 3 years Annually, submit electronic reports of influenza vaccination coverage to CDPHE Achieve vaccination target (phased-in approach) ― 2012 = 60% ― 2013 = 75% ― 2014 forward (NOW) = 90% 10

11. What if your facility does not reach 90%? Requirements for ASC, Hospitals, LTC If you are a hospital, long term care facility or an ASC and do not achieve 90%, you must: provide or make available influenza vaccine. implement a mandatory HCW influenza vaccination policy that requires annually either proof of vaccination or a signed medical exemption (signed by licensed physician, PA, advanced practice nurse, nurse midwife). require any unvaccinated HCW, incl those with medical exemptions, to wear a surgical or procedure mask (provided by facility) during flu season (Nov 1 – Mar 31) when in direct contact w patients and in common areas. 11

12. 2 Ways to Report HCW Flu Data National Healthcare Safety Network (NHSN-CDC) – required if reimbursed by CMS acute care hospitals dialysis facilities (per CMS, starting Oct 2015) psych hospitals (per CMS, starting Oct 2015) ASC (111 of 124 CMS certified) State Portal (CDPHE) assisted living residences, long term care/skilled nursing facilities home health care agencies community clinics rehabilitation centers community mental health centers facilities for persons with developmental disabilities hospice care birthing centers convalescent centers Facility must submit data into ONE SYSTEM ONLY!! Do NOT report into both! 12

13. CMS Requires NHSN Reporting Centers for Medicare & Medicaid Services (CMS) started requiring certain types of facilities to report HCW flu vaccination data using NHSN If you get reimbursed for Medicare patients, you must report through NHSN Colorado BOH Rule was in place before CMS requirement CMS participating facilities should only report once into NHSN; this fulfills both Colorado Rule and CMS requirements but must join Colorado group (27648) and confer rights to CDPHE You only need to submit data into one system!! 13

14. Who to Include/When to Submit Data It’s Confusing! National Health Safety Network (CDC) For denominator: Count staff who worked from Oct 1 – Mar 31 Days employees must work = 1 day Includes volunteers Includes other contract workers but this is optional Vaccinated by Mar 31 Submit data = May 15 State Portal (CDPHE) For denominator: Count staff who worked from Oct 1 – Dec 31 Days employees must work = 1 day (rev from 30 days to align w NHSN) Volunteers are optional Vaccinated by Dec 31 Submit data = March 31 14

15. Using NHSN to Enter HCW Flu Data ASC that participate in CMS reimbursement programs or perform certain types of surgeries required to use NHSN. NHSN – secure, web-based electronic reporting system used by thousands of health care facilities to report HAI, HCW flu data Any facility that reports through NHSN must 1st enroll into SAMS (Secure Access Management System) and NHSN… a multi-step process that can take several weeks. If NHSN is used, the user must add the Healthcare Personnel Safety component to enter data, join Colorado group (27648) & confer rights to state. Only NHSN Facility Administrator can add/edit components. 15

16. What exactly must be entered for HCW Flu? NHSN - Healthcare Personnel Safety Component 1. Annual Flu Survey (once yearly in Februray) 2. Reporting Plans (monthly, but only need to enter ONE month, NHSN enters remaining months) 3. Flu Summary Data (once yearly by May 15)  I brought written instructions. 16

17. Health Facilities Portal – Step 1: Sign In www.cohfportal-egov.comwww.cohfportal-egov.com OR https://www.hfemsd4.dphe.state.co.us/hfportal/hfstart.aspx Each facility has a portal administrator with a user name and password; If you don’t know who that is, call CDPHE’s Licensure Customer Assistance at 303-692-2836 17

18. Reporting Tips for HCW Flu Data National Health Care Safety Network If your facility reports to CMS, you should report through NHSN or If your facility performs any of the state reportable surgeries, you should report HCW Flu Immunization data through NHSN Only NHSN facility administrator can add Healthcare Personnel Safety, join Colorado group and confer rights to CDPHE to see your data NHSN Help Desk - nhsn@cdc.govnhsn@cdc.gov Call Tamara Hoxworth @ 303-692-2930 Health Facilities State Portal If you don’t report to CMS or perform any state reportable surgeries, you can report through state portal Identify your state portal administrator – every facility has one (one administrator per facility, multiple users) Chrome or Mozilla Firefox are preferred search engines. Some have problems using Internet Explorer. The following URL should help https://www.hfemsd4.dphe.state.co.us/hfportal/hfstart.aspx https://www.hfemsd4.dphe.state.co.us/hfportal/hfstart.aspx Call Licensure Customer Assistance @ 303-692-2836 **Recommend saving/printing screenshot of completed flu summary screen! 18

19. Public Disclosure Report - 2016 Summer 2016, our annual HCW influenza summary report will publish reporting status of individual facilities including whether or not they reported vaccination compliance percentage 19

20. For more info on HCW flu reporting in CO 20 https://www.colorado.gov/pacific/cdphe/board-health-rule-influenza-immunization

21. Colorado HAI Disclosure Statute Passed May 2006, Health facilities began reporting by 7/31/2007; ASC began reporting Oct 2008 w reporting of hernia repairs. 6 Main Conditions: 1. Healthcare facilities shall report HAI as condition of licensure. 2. Healthcare facilities are required to use NHSN to submit HAI/SSI data 3. Physicians ensure HAI diagnosed at FU visits be reported to facilities where procedures were done. 4. CDPHE lead agency to implement HAI legislation. 5. CDPHE to provide and annual HAI Disclosure report to legislature/public. (I BROUGHT COPIES) 6. CDPHE’s Executive Director shall appoint HAI Advisory Committee 21

22. Colorado HAI Advisory Committee 11 members - experts from Colorado health care community, including a dedicated position for a rep from ASC Meet monthly or bimonthly Provide expert consultation, guidance in implementing legislation Select clinical procedures and organisms to track and report Help assure quality, accuracy of reports by providing clinical input/ critical review Help establish connections, credibility and buy-in 22

23. HAI Reporting in Colorado  > 300 healthcare facilities in CO targeted to report HAI, but not all perform reportable procedures.  Reporting Facilities (221):  77 Acute care hospitals  9 Long Term Acute Care (LTAC) hospitals  58 Ambulatory Surgery Centers  72 Outpatient Dialysis Centers  5 Rehabilitation Hospitals  Current Reportable Infections:  Central Line-Associated Bloodstream Infections: Acute Care Hospitals, Long-Term Acute Care Hospitals, and Rehab Hospitals  Dialysis Related Infections: Outpatient Dialysis Centers  Clostridium difficile and MRSA: Acute Care Hospitals Only  Surgical Site Infections: Hospitals and ASC 23

24. State Reportable Surgeries/SSI Breast Cardiac Colon Hernia Hip Replacements Knee Replacements Abdominal Hyst Vaginal Hyst 24

25. How are they reported? Into NHSN! National Healthcare Safety Network (NHSN) Electronic, secure web-based HAI surveillance and data-reporting system maintained by Centers for Disease Control and Prevention in Atlanta Collects data on  Healthcare-associated infections includingSSI  Healthcare personnel influenza vaccination  Biovigilance (blood safety)  Anti-microbial use and resistance Used by CO to collect data for state HAI reporting requirements and HCW Flu Immunization reporting requirements Used by CMS if you participate in Quality Reporting for reimbursement purposes 25

26. NHSN Components

27. What are NHSN data used for? Provides facilities, states, regions, and nation with data collection and reporting capabilities to: identify infection prevention problems by facility, state, or specific quality improvement project measure progress of infection prevention efforts comply with state and federal public reporting mandates, and ultimately, drive national progress toward elimination of HAIs. 27

28. What exactly must be entered for SSIs? NHSN - Patient Safety Component 1. Annual Facility Survey (once yearly in February) 2. Reporting Plans (monthly, but may do all at once) 3. All reportable surgeries (monthly, even when there are no SSI/events: denominator for procedure form) 4. Events, (SSI, if you have any on the event form)  See copy of NHSN SSI Event Protocol – www.cdc.gov/nhsnwww.cdc.gov/nhsn  CDPHE Training for SSI reporting-Carolyn Elliott 303-692-2923 28

29. Final Words Surgeries/SSI reportable for ASC in NHSN Patient Safety Component HCW Flu Immunizations reportable in NHSN Healthcare Health Care Personnel Safety Component (unless using state portal) For CDPHE to see your data, you must ensure you have added these components and their corresponding groups and accepted the confer rights template for each component. Patient Safety – Colorado Group 11351 Health Care Personnel Safety – Influenza Reporting Group 27648 29

30. Reporting Resources/Contact Info. HCW Flu NHSN webpage www.cdc.gov/nhsnwww.cdc.gov/nhsn NHSN Help Desk nhsn@cdc.govnhsn@cdc.gov State Immunization Webpage https://www.colorado.gov/pacific/cdphe/board-health-rule- influenza-immunization Tamara.Hoxworth@state.co.us 303-692-2930 Tamara.Hoxworth@state.co.us Erica.Bloom@state.co.us 303-692-2789 Erica.Bloom@state.co.us Licensure Customer Assistance Line at 303-692-2836 SSI Reporting NHSN webpage www.cdc.gov/nhsnwww.cdc.gov/nhsn NHSN Help Desk nhsn@cdc.govnhsn@cdc.gov CDPHE Technical Assistance-Tamara Hoxworth 303-692-2930 CDPHE SSI Training – Carolyn Elliott 303-692-2923 30

31. THANK YOU!!! 31 Questions??

32. Total Facilities/Number Reporting 32

33. NHSN Entry Screen-Step 1: Choose Component & Group 33

34. NHSN Step 2-Add Reporting Plan 34

35. NHSN Step 3-Complete Reporting Plan 35

36. NHSN Step 5-Add Flu Data 36

37. Health Facilities Portal-Step 2: Click Flu Vaccination Reporting 37

38. Health Facilities Portal-Step 3: Enter Year 38

39. Health Facilities Portal-Step 4: Enter Data into Flu Summary Screen 39 For 2015/16 data, this will read “1 day” rather than 30 days between Oct 1 – Dec 31