PAGE: 1 of 3 / REPLACES POLICY DATED: 1/1/12
EFFECTIVE DATE: May 15, 2012 / REFERENCE NUMBER: CSG.COM.004
APPROVED BY: Ethics and Compliance Policy Committee
SCOPE: All eligible HCA acute care hospitals and Long Term Care Hospital (LTACH) Facilities and Inpatient Rehabilitation facilities freestanding or units within acute care hospitals with a signed Notice of Participation indicating inclusion in the CMS Hospital Inpatient Prospective Payment System (IPPS) as follows:
1. Central Line Associated Bloodstream Infections (CLABSI) from ICU adult, pediatric and neonatal patients (as of January 2011);
2. CLABSI from LTACH patients (as of October 2012);
3. Catheter Associated Urinary Tract (CA-UTI) Infections from adult and pediatric ICU patients (as of January 2012);
4. CA-UTI from LTAC and Inpatient Rehabilitation facilities (as of October 2012);
5. Surgical procedures and post-operative Surgical Site Infections for Colon resections (COLO) and abdominal hysterectomies (HYST); and
6. Although an exception to the IPPS mandated reporting, Ventilator Associated Pneumonia (VAP) from ICU adult, pediatrics and neonatal patients will be reported into the NHSN application (as of January 2012).
PURPOSE: To assist all eligible HCA facilities in complying with the reporting requirements of the CMS mandated programs in order to receive the full annual inpatient payment update (APU).
To facilitate compliance with NHSN rules of behavior and reporting requirements.
To facilitate timely, accurate and complete data collection and reporting across all eligible HCA acute care hospitals, LATCH and Inpatient Rehabilitation facilities.
POLICY:
HCA Facilities
All HCA facilities will follow NHSN/CDC reporting for CLABSI, CA-UTI, VAP, COLO and HYST as designated within the NHSN facility reporting declaration plan. Monthly NHSN reporting is required on or before 30 days after the close of the reporting month, as defined in the NHSN participant rules.
1. All HCA facilities meeting the NHSN requirements to sign up with NHSN-CDC will complete the appropriate confirmation to share their NHSN-CDC data.
2. All HCA facilities will file applicable exemption forms.
3. All HCA eligible facilities must appoint two administrators with conferred rights to enter their facility’s data at NHSN-CDC.
4. All HCA eligible facilities will submit their monthly CLABSI data in a timely manner as outlined in this policy.
5. All HCA eligible facilities will submit their monthly CA-UTI data in a timely manner as outlined in this policy.
6. All HCA eligible facilities will submit their monthly COLO and HYST data in a timely manner as outlined in this policy.
7. All eligible HCA facilities will enroll in the NHSN/CDC application and notify HCA Clinical Analytics of any qualifying patient locations being renamed, repurposed to level of care, newly designated or added to active service.
8. The Infection Preventionist (IP) or individual reporting the required NHSN data, will notify the CFO when monthly reporting is complete. The facility CFO is responsible for verifying reporting is complete within 30 days.
9. Clinical Analytics and Infection Prevention will follow up through the DVPQ, who will contact the CFO, when data is incomplete or not valid.
The Clinical Analytics and Infection Prevention team in the Corporate Clinical Services Group will:
1. Check on a quarterly basis that all HCA facilities are signed up to submit their required data at the NHSN-CDC site;
2. Annually confirm with each facility there are two administrators set at each facility to enter the facility’s data at the NHSN-CDC site;
3. In collaboration with Infection Prevention and Control, will review on a monthly basis the entry of each facility’s NHSN-CDC data; and
4. Notify facilities of successful status and escalate when data is incomplete or not valid.
PROCEDURE:
Hospital
1. Enroll facility in NHSN and consent to share data with CMS by designated deadlines.
Note: Continue to follow state mandated reporting requirements.
2. When qualified by having no ICUs or CAH Critical Access Hospital, file exclusion form with CMS and send file copies of enrollment to Quality Manager of Clinical Analytics.
3. Designate primary and secondary facility administrators in NHSN and send names to Quality Manager of Clinical Analytics. Note: A primary and secondary facility administrator must be actively designated at all times.
4. Notify Quality Manager of Clinical Analytics of changes in exclusion designation or NHSN facility administrators within 5 business days.
5. Join your facility to the HCA group [16599] by contacting the Quality Manager of Clinical Analytics or the Clinical Services Group Infection Prevention Team for each qualifying reportable group.
6. All eligible HCA facilities will enroll into the NHSN/CDC application and notify HCA Clinical Analytics of any qualifying patient locations being renamed, repurposed to level of care, newly designated or added to active service within the reporting month.
7. Report the CLABSI patient case numerators and device day denominators into the NHSN database, on a monthly basis on or before 30 days after the close of the reporting month.
8. Report the CA-UTI patient case numerators and device day denominators into the NHSN database, on a monthly basis on or before 30 days after the close of the reporting month.
9. Report the COLO and HYST patient case numerators and the procedure case denominator elements into the NHSN database, on a monthly basis on or before 30 days after the close of the reporting month.
10. Discontinue reporting into Streetwise ending with: 3Q2011 Adult and Pediatric CLABSI and VAP, 4Q2011 NICU CLABSI and VAP.
11. Noncompliance with the CMS/NHSN/HCA CLABSI requirements will place the hospital in jeopardy of not receiving their Annual Payment Update (APU), which is 2% of the hospital’s Medicare Reimbursement.
Clinical Analytics
1. By 21 and 30 days after the month and 21 and 30 days after the calendar quarter, Clinical Analytics will review the HCA Group members and the data entered through a tracking of facilities listed and an analysis of the data from the reports available at the NHSN-CDC site.
2. Lack of compliance by a facility in maintaining vigilance in data entry and NHSN-CDC membership noted by the Clinical Analytics review will merit notification to:
a. The VP of Clinical Analytics and AVP of Infection Prevention;
b. Hospital Contact Notification to the CFO; and
c. DVPQ Notification.
REFERENCES:
1. CMS Reporting Program FY 2013 payment determination: http://qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1138115987129
2. NHSN/CDC: http://www.cdc.gov/nhsn/enroll.html
4/2012