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NHSN 10_3Hello everyone and thank you for joining us today for this training. I’m going to turn the mic over to Elizabeth shortly, but first, I wanted to say if you have any questions during the presentation, type them into the question pod on the screen and we will read them aloud and answer them for all attendees at the end of the formal presentation. Now I will hand things over to Elizabeth.Thanks, Megan. Welcome to the Healthcare Personnel Safety Component Training Session for the Influenza Vaccination Summary of the Healthcare Personnel Vaccination Module. My name is Elizabeth Kalayil, and I work as a contractor in the Immunization Services Division at CDC. I’ll be presenting information during the first half of the webinar. This presentation will cover several topics. The first objective is to provide an overview for NHSN users on the Healthcare Personnel Safety Component. We will then review the reporting requirements for the Healthcare Personnel Vaccination Module. Next, we’ll go over how to enter data in the module and how to verify successful submission of data. Now we’ll go over a few aspects of using the Healthcare Personnel Safety Component. To combat NHSN access issues due to staff turnover, vacation or extended leave, we recommend that each facility has at least two individuals who can add, edit, delete, and analyze the healthcare personnel influenza vaccination summary data at all times in NHSN. To add an additional user to your facility, click on ‘users’ and then ‘add’ on the left-hand navigation bar. On the add user screen, complete all fields that are marked with an asterisk. The user ID can be any combination of letters and numbers; for example, the user’s first initial and last name, or the user’s internal employee ID number. Next, please enter the user’s first name, last name, phone number and e-mail address. Then click ‘save.’ The edit user rights screen will appear after you save the new user information. Select the appropriate level of rights to give to the new user. This step must be completed for new users to have access to any of the system features within the Healthcare Personnel Safety Component. If you’re unsure about the level of user rights to assign to a new user, please contact the NHSN HelpDesk for assistance.Once the new user information has been saved, that user will receive an automated “Welcome to NHSN” e-mail with instructions to begin the process of becoming an NHSN user. After agreeing to the NHSN rules of behavior, the new user will receive an automated e-mail to register with SAMS. SAMS stands for Secure Access Management Services and provides secure online access to CDC applications. All NHSN users are required to complete the same SAMS identity verification process prior to gaining access to NHSN. After registering with SAMS, the new user receives instructions to create a SAMS account and complete an identity verification process. During this process, new users should be sure to follow the instructions carefully to prevent delay in processing the documentation. The user will receive confirmation from SAMS once these documents are approved and a SAMS grid card will be delivered to your home address. They will then be able to access the NHSN facility using SAMS credentials.Please keep in mind that the new user has 30 days to begin the SAMS registration process and 60 days to return the identity proofing documentation. If those deadlines are not met, the user will need to reach out to the NHSN helpdesk to be re-invited to SAMS to start the process from the beginning. Please note that it will take at least 2 to 3 weeks for a new user to be able to access NHSN. CDC recommends that new users begin the onboarding process well in advance of the reporting deadline. Users should be sure to login to NHSN using their SAMS card at least one time each year so that it will remain active. Please note that if your account is inactive and you try to enter your data, this may delay your reporting.Because the SAMS card is user-specific and not-facility specific, an individual with user access to multiple NHSN facilities through the same e-mail address could enter data into multiple NHSN facilities using the same single SAMS card. Additionally, an individual can keep their SAMS card and simply change the e-mail address on the SAMS account if they should begin working at a new facility. More information about the SAMS process can be found using the link listed on the slide. NHSN highly recommends that if there is a change in the NHSN facility administrator, then he or she should transfer that role to another user in NHSN prior to leaving the facility. This saves a significant amount of time for the newly designated facility administrator and prevents a gap in access to your NHSN facility. If the previously designated NHSN facility administrator has left your facility prior to re-assigning that role to another person, you will need to reach out to the NHSN HelpDesk to have that role manually re-assigned to the new administrator. To complete this process, a letter must be faxed to the NHSN HelpDesk using the number listed on the slide. The letter should be from an official at your facility requesting that you be assigned as the new NHSN facility administrator since the previous administrator is no longer with your facility. In addition to the name and e-mail address of the new facility administrator, the letter should include the name and e-mail address of the old facility administrator as well as the facility name and 5-digit NHSN ID number, if known. Please do not re-enroll this facility in NHSN. After the NHSN HelpDesk receives the fax and completes the re-assignment, the newly designated facility administrator will receive the welcome to NHSN e-mail to start the new NHSN user onboarding process. If the newly assigned facility administrator is already an NHSN user with a SAMS card, no further action is required. Now we will review the specific reporting requirements for the healthcare personnel influenza vaccination summary data. There are three required denominator categories. The first required denominator category is employees who are defined as all persons receiving a direct paycheck from the healthcare facility regardless of clinical responsibility or patient contact. The second denominator category consists of non-employee licensed independent practitioners, specifically physicians, advanced practice nurses, and physician assistants who are affiliated with the healthcare facility, but are not on the facility’s payroll, regardless of clinical responsibility or a patient contact. This category also includes post-residency fellows. The third required denominator category consists of non-employee adult students, trainees and volunteers who are age 18 and over. This is defined as medical, nursing or other health professional students, interns, medical residents, or volunteers age 18 or older who are affiliated with the healthcare facility that are not on the facility’s payroll, regardless of clinical responsibility or patient contact. The fourth denominator category consists of non-employee contract personnel. Reporting for this category is optional at this time. Contract personnel are defined as persons providing care, treatment, or services at the facility through a contract who do not fall into any of the other denominator categories. Some examples include dialysis technicians, occupational therapists, admitting staff, and pharmacists. Please refer to appendix A of the Healthcare Personnel Influenza Vaccination Summary Protocol for a suggested list of contract personnel. If a facility decides to report contractor data, it can note which categories of contract personnel are included in their data by using the comments function in NHSN. Now we will review the numerator categories. The first numerator category is healthcare personnel who receive an influenza vaccination either at this healthcare facility or elsewhere. Please note that these are two separate fields in the NHSN module. The first field includes healthcare personnel who received an influenza vaccination at this healthcare facility since influenza vaccine became available this season. The second field includes healthcare personnel who were vaccinated outside this healthcare facility since influenza vaccine became available this season and provided a written report or documentation of influenza vaccination. Acceptable forms of documentation include a signed statement or form in electronic form, or e-mail from the healthcare worker, or a note, receipt, or vaccination card from the outside vaccinating entity. Verbal statements are not acceptable for the module.The second numerator category is healthcare personnel who have a medical contraindication to the influenza vaccine. For this measure, for inactivated influenza vaccine, accepted contraindications include a severe allergic reaction after a previous vaccine dose, or to a vaccine component including egg protein, or a history of GBS within 6 weeks after a previous influenza vaccination. Healthcare personnel who have a medical contraindication to live attenuated influenza vaccine, other than a severe allergic reaction to the vaccine component, or history of GBS, should be offered inactivated influenza vaccine by their facility if that’s available. Therefore, the medical contraindications stated above are the only accepted contraindications for the module. Please note that documentation is not required for reporting medical contraindications, so verbal statements are acceptable.The third numerator category is healthcare personnel who are offered and declined to receive the influenza vaccine. Documentation is not required for reporting declinations. The fourth numerator category is healthcare personnel with unknown vaccination status, or they did not meet any of the criteria for the other numerator categories.This slide reviews a few points about reporting requirements. Facilities only need to report data through NHSN once at the conclusion of the reporting period. Healthcare personnel in the denominator population who receive an influenza vaccination during the time when the vaccine became available, for example, August or September, through March 31st of the following year are counted as vaccinated since influenza vaccine for a given season may be available as early as August or September. For example, an employee who receives the influenza vaccine in August and physically works in the facility for one day or more from October 1st through March 31st should be included in the data. Also, long-term acute care facilities participating in the CMS and Patient Quality Reporting program are still required to report healthcare personnel influenza vaccination summary data through NHSN, although reporting patient influenza vaccination reporting is no longer required. Now I will turn the presentation over the Megan Lindley, and she will review data entry.Thanks, Elizabeth. Now we will go over how to login to NHSN through SAMS. You can access the SAMS activity homepage by clicking on the link listed on this slide. You will then need to enter your SAMS username and password followed by your SAMS grid card numbers. If you have questions or need assistance with using SAMS, please contact the SAMS HelpDesk by phone or by e-mail using the information listed on this slide. This slide shows the NHSN landing page. Select the appropriate component, which in this case is Healthcare Personnel Safety, and the facility from the dropdown boxes. Next, click the ‘submit’ button to proceed. While you are navigating through NHSN, you should use the NHSN buttons and not the web browser buttons to move forward and back. When navigating through NHSN, you can always see which facility, user and component are in use at the top of the screen as shown in the screenshot at the bottom of this slide. This slide shows the Healthcare Personnel Safety Component homepage. You will see that there’s a navigation bar on the left side of the page which can be used to access different parts of the module. This slide shows what facilities will see on their screen in NHSN when adding a monthly reporting plan in the HPS Component. To add a monthly reporting plan, click ‘reporting plan’ and then ‘add’ on the left-hand navigation bar. Select the correct month and year from the dropdown menus. For example, if you are reporting data for the 2019-2020 influenza season, you can select October 2019 for your monthly reporting plan. It is very important to correctly submit your monthly reporting plan which includes identifying the correct influenza season because reporting plans that identify the wrong influenza season will not allow your data to be submitted in fulfilment of CMS requirements. The user should check the box next to influenza vaccination summary under the Healthcare Personnel Vaccination Module heading. After making the appropriate selections, the user must click ‘save.’ To enter vaccination summary data, go to ‘add’ under flu summary on the left-hand navigation bar. Click continue to proceed as influenza vaccination summary data appears as the default option on the dropdown menu. Please remember that you will not be able to enter a summary data report until you have first added your monthly reporting plan as shown on the previous slides.This is what facilities will see on their screen in NHSN when adding influenza vaccination summary data reports. You must complete all fields marked with an asterisk on this page. Influenza and seasonal are the default vaccination type and influenza subtype choices. The user will then select the appropriate flu season in the dropdown box. For example, again, if you are reporting data for the 2019-2020 influenza season, you must select 2019-2020 in the dropdown box for flu season. This is very important since data submitted under the incorrect influenza season will not be shared with CMS and will therefore not fulfill their quality reporting requirements. Facilities can always contact NHSN if they are unsure of which influenza season is currently being reported. This slide shows what the data entry screen looks like in the NHSN module. The asterisks on the screen indicate the columns that must be completed. Users can use the tab key on a computer keyboard to move across columns. Users should enter a zero in the field if no healthcare personnel at the facility fall into that category. Again, because those columns marked with asterisks are required, you cannot leave them blank, but you can enter a zero if there are no healthcare personnel that fall into that category.The comments box shown at the bottom of the screen can be used to enter additional information which are usually side notes or reminders. However, please note this information cannot be analyzed within NHSN. Once your summary data have been entered, click the gray save button to save the record. Please note that the summary record must be entered into NHSN prior to the May 15th reporting deadline in order to have your data shared with CMS. Any data that are entered after the May 15 reporting deadline will not meet the submission requirements for the CMS long-term care hospital quality reporting, or LTCHQR program. For each update of the influenza vaccination summary data after the initial entry, you will see a message at the top of the screen indicating that a record of the summary data for that season already exists. The date last modified shows when data were last entered and saved. If you would like to edit or update your facility data, simply click the edit button at the bottom of the screen to modify existing data. Once you have completed any required edits, please be sure to save the updated data by clicking the save button at the bottom of the screen. You should see a message confirming that your data have been saved. This will appear at the top of your screen and the date last modified will automatically be updated by NHSN.We will now briefly review the steps facilities can take to verify that their data have been entered correctly and will be submitted to CMS. After summary data have been entered into NHSN, users can verify that the data have been saved correctly by running a report within the NHSN analysis feature. This report can be found in the CMS reports folder under the long-term acute care hospital sub-folder. By clicking the gray ‘run report’ button, the facility can review the healthcare personnel influenza vaccination data by influenza season stratified by healthcare personnel category which are those employees, licensed independent practitioners, and adults, students, trainees and volunteers, as well as all three categories combined. This report shows the exact information that will be submitted to CMS for your facility. Remember that by default the results will appear in a separate HTML window. If a second window does not appear when you click the run button, please be sure to check your pop-up blocker and allow pop-ups from . You can refer to the link on this slide for step-by-step guidance for running and interpreting this report. In addition to running the CMS line listing report described on the previous slide, facilities can confirm two other pieces of information within NHSN to ensure their data will be shared with CMS appropriately. Both of these pieces of information can be found on the facility information screen within NHSN. To get to the facility information screen, click on ‘facility’ and then ‘facility info’ in the left-hand navigation bar. First, verify that the correct facility CMS certification number, or CCN, and CCN effective date have been entered correctly. Your CCN effective date should be the date your facility first received its CCN from CMS. You also need to ensure that your facility is enrolled in NHSN as the correct facility type. All long-term acute care hospitals should be enrolled as the facility type HOSP-LTAC. If your facility is not correctly enrolled, please contact NHSN@ for assistance. This is very important, as only data from facilities enrolled as the HOSP-LTAC facility type will be shared with CMS for the LTCHQR reporting program. As long as your data appear in the CMS line listing for the current reporting period, your CCN and CCN effective date are correct, and your facility is enrolled as the correct facility type, no further action is required on your part. Your data will be shared with CMS following the reporting deadline. Please note that NHSN does not provide a confirmation email to facilities once they have submitted their data. CDC recommends that facilities maintain printed copies or screenshots of this data entry for their records.Facilities can visit the NHSN website using the link on this slide. The website contains links to the Healthcare Personnel Safety Component protocol, data collection forms, frequently asked questions, comprehensive training slides, and recorded trainings for healthcare personnel influenza vaccination summary reporting from previous seasons. Please note that the comprehensive training slides include more detail on topics such as NHSN enrollment, how to activate the HPS component in NHSN, and data reporting and analysis features. Therefore, new facilities may find it helpful to also refer to those slides. If you have any questions about NHSN, please send an email to user support at NHSN@. You should also include HPS flu summary in the subject line of the email and specify that you are a long-term acute care hospital, as this will help the e-mail to be triaged to us more quickly so that we can better assist you. This concludes the slide presentation for the webinar, and we will now have the opportunity to answer questions. Again, if you have any questions about healthcare personnel vaccination reporting through NHSN, you can enter them into the question box that is on the screen.The first question we received is if healthcare personnel work offsite and gets a direct paycheck, should they be included in the denominator? So, for the purposes of this reporting, only healthcare personnel who work physically in your long-term acute care hospital at least one day between October 1st and March 31st of the following year should be counted. So even if that person has a direct paycheck from you, if they do not ever physically work in your facility, they would not be included in your denominator.Another question we had was what do you do if you do not receive the automated e-mail from NHSN for SAMS? So during this process, if you don’t receive communication from NHSN and you’re expecting some, you can go ahead and send a follow-up e-mail to NHSN@ and let them know that you are in the process of being a new user for NHSN and that you did not receive that e-mail, and you can put in your subject line ‘new user to NHSN’ and that should help with triaging your request. So that’s one thing you can do.If you do not ask a question now and think of one later, you can of course always send your question to that NHSN@ e-mail address. We received a question: How do I know if my hospital is listed as a long-term acute care hospital in NHSN? So, what you should do is login to your facility in NHSN, navigate to the facility info page under the facility heading, and the enrollment of facility type, fact type, will be listed on that page. If for some reason you are a new user or you don’t have access to that information and cannot get it from your facility administrator, you can always e-mail NHSN at NHSN@. Give us the name of your facility, and if you know your NHSN org ID number that’s helpful, if you can provide your CMS certification number, that’s helpful, and we can look it up for you and let you know if you’re enrolled as the correct facility type.While we’re waiting for any additional questions, I did want to point out to people that if you would like to get a copy of these slides so you have access to the links that we shared, the presentation is available for download here in the connect pod. So, we have another question. Is this only for hospitals and not long-term care facilities? So, yes, this training covers long-term acute care facilities and they’re still required to report flu vaccination data. However, long-term care facilities are separate, and they are not required by CMS to report flu vaccination data at this time. Of course, long-term care facilities who are interested in reporting data can do so voluntarily and we would be happy if they could do that. It’s certainly available and they’re able to do that if they wish. So, yes, we have two facility types, long-term acute care and long-term care.We received another question. Just to clarify, any contracted healthcare personnel are optional to enter into the influenza vaccination summary. This person states that’s a large portion of their staff and so they’re usually reported. So, for the purposes of CMS reporting requirements, personnel who fall into that other contract personnel category are optional. It doesn’t matter who they are. The exception, to remind you, is that a licensed independent practitioner which is required reporting, includes any physician, nurse in advanced practice, or physician assistant who is not a direct employee. So, if your contract personnel are physicians, nurses in advanced practice, or physician assistants, they would be part of the required reporting, but otherwise any other contracted personnel are optional at this time. You may be required to report them for the purposes of Joint Commission accreditation or other requirements that apply to your facility, but for CMS and NHSN they are optional.We have another question that says is the process the same for the hospital? So, acute care facilities are still required to report data to NHSN. I think one of the biggest differences is that acute care facilities may have other units that are required to report to CMS, so for example they may have an inpatient rehab facility unit within the acute care hospital and then if that’s the case, they would have to report data for their acute care facility and their CMS inpatient rehab unit that’s located within the hospital. So, I think that’s really one of the major differences for the facility types.Just to add to that, if you are not certain if you are responsible for reporting for an acute care hospital and a long-term care hospital and you are not certain whether both of those facilities are enrolled or available to you in NHSN, we can always assist you with that in NHSN@ and the more information you can provide about the facility the better, because it makes it easier for us to find it in the database. Again, the question que is currently empty. We will wait another minute or so to see if there are additional questions….Okay, so the question is: are students who do clinicals in our facility counted in the denominator? Absolutely. If those students, assuming they’re doing clinicals as part of training, that means they’re over 18 and over. They would be counted in that adult, student, trainees, and volunteers category. So just to reiterate, that’s any student or trainee or volunteer who is working in the facility for one day or more between October 1st and March 31st, so if their clinical rotation overlaps that time period, yes, you should include them in the denominator.So now seeing no further questions, I will go ahead and give you some time back. Again, if you think of a question later, please feel free to e-mail us at NHSN@. Specify that we’re talking about healthcare personnel flu summary reporting for long-term acute care in the subject line and we will be happy to assist you. Thank you very much for joining us today and you can now leave the webinar.END. ................
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