PAGE: 1 of 3 / REPLACES POLICY DATED:
EFFECTIVE DATE: January 1, 2012 / REFERENCE NUMBER: CSG.COM.004
APPROVED BY: Ethics and Compliance Policy Committee
SCOPE: All eligible HCA hospitals with a signed Notice of Participation indicating participation in the Hospital Inpatient Prospective Payment System (IPPS) must report the following:
1. Central Line Associated Bloodstream Infections (CLABSI) from ICU adult, pediatric and neonatal patients;
2. Catheter Associated Urinary Tract (CA-UTI) Infections from adult and pediatric ICU patients; and
3. Surgical procedures and post-operative Surgical Site Infections for Colon resections (COLO) and abdominal hysterectomies (HYST).
PURPOSE: To assist all eligible HCA facilities in complying with the reporting requirements of the CMS IPPS program 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 hospitals.
POLICY:
HCA Facilities
All HCA facilities will follow NHSN/CDC reporting for CLABSI, CA-UTI, 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 eligible facilities must appoint two administrators with conferred rights to enter their facility’s data at NHSN-CDC.
3. All HCA eligible facilities will submit their monthly CLABSI data in a timely manner as outlined in this policy.
4. All HCA eligible facilities will submit their monthly CA-UTI data in a timely manner as outlined in this policy.
5. All HCA eligible facilities will submit their monthly COLO and HYST data in a timely manner as outlined in this policy.
6. The Infection Preventionist (IP) or individual reporting the required NHSN data, will notify the CFO when reporting is complete. The facility CFO is responsible for verifying reporting is complete within 30 days.
7. Clinical Analytics will follow up through the DVPQ, who will contact the CFO, when data is incomplete or not valid.
The Clinical Analytics team in the Corporate Clinical Services Group:
1. Will check on a quarterly basis that all HCA facilities are signed up to submit their required data at the NHSN-CDC site;
2. Will annually confirm with each facility there are two administrators set at each facility to enter the facility’s data at the NHSN-CDC site; and
3. In collaboration with Infection Prevention and Control, will review on a monthly basis the entry of each facility’s NHSN-CDC data.
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 (click on this hyperlink for the 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 (CLABSI – all ICUs, CA-UTI adult and pediatric ICUs, COLO and HYST procedures).
6. 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.
7. 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.
8. 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.
9. Until notified, continue to also report CLABSI data into the HCA Streetwise application. Streetwise data is due quarterly, 45 days after the end of the quarter.
10. 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 fifteen days after the month and after the calendar quarter, Clinical Analytics will review the HCA Group members and the data entered through a tracking of facilities listed and a 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:
CMS Reporting Program FY 2013 payment determination: http://qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1138115987129
NHSN/CDC: http://www.cdc.gov/nhsn/enroll.html
12/2011