Qsource Data Reporting Assistance Lesley Hays – Patient Care Improvement Manager

2. Qsource Data Reporting AssistanceLesley Hays – Patient Care Improvement Manager

3. Discussion Points • FY 2015 Validation • Background • CLABSI, CAUTI, SSI – COLO/HYST • CLABSI/CAUTI Validation • Steps Involved • Responsibilities • Resources & Support • Deadlines

4. Background • FY 2015 Annual Payment Update (APU) Determination (FY 2015 Reference Checklist) • Submit Healthcare Associated Infections (HAI) data (http://www.cdc.gov/nhsn/cms/) • Hospitals collect and submit data to Centers for Disease Control and Prevention (CDC) through the National Healthcare Safety Network (NHSN). • Central Line-Associated Bloodstream Infection (CLABSI) data (ICU) • Catheter-Associated Urinary Tract Infection (CAUTI) data (ICU) • Surgical Site Infection (SSI) abdominal hysterectomy and colon surgery data (all) • Methicillin-resistant Staphylococcus aureus (MRSA) data (all) • Clostridium Difficile (C. Diff) data (all) • Healthcare Personnel Influenza Vaccination (all) • Hospitals with no ICU location and/or that performed 9 or fewer of any of the specified colon and abdominal hysterectomy procedures in the calendar year prior to the reporting year, can request an HAI exception for submission of CAUTI, CLABSI and SSI measures to fulfill the CMS Hospital IQR Program NHSN reporting requirement.

5. Background, cont. • 400 Hospitals at random, with additional 200 hospitals targeted • 15 records selected per quarter for chart-abstracted clinical process of care measures (SCIP, HF, AMI, PN, ED/IMM) • 12 records selected per quarter for HAI measures • Pass validation requirements • Receive a Confidence Interval of 75 percent or greater based on the combined chart audit validations for 4Q12 - 3Q13 discharges. • Submit HAI Validation Templates via QNet each quarter: • Validation Blood Culture Template • Validation Urine Culture Template • SSI COLO/HYST • Q4 2012,Q1 2013, Q2 2013, Q3 2013

6. Validation Methodology • Basics for Candidate CLABSIs: • Final results for positive blood cultures for patients who were in the ICU when the blood culture was drawn • Presence of a central venous catheter (CVC) any time during the stay (including on admission) • Basics for CAUTIs: • Final results for all positive urine cultures with greater than or equal to 103 colony-forming units (CFUs)/ml • ICU admission during the hospital stay

7. Sample CLABSI Validation Steps - LEGEND Hospital Iowa QIO (CMS Support Contractor) QIO Clinical Warehouse Centers for Disease Control and Prevention (CDC) Clinical Data Abstraction Center (CDAC)

8. Sample CLABSI Validation Steps • Identify candidate CLABSI events • Populate Blood Culture template • Submit Blood Culture template to CMS Contractor (Iowa QIO) via QNet by quarterly deadline • QNet Security Administrator • Iowa QIO loads all data from the Blood Culture template into large database • Positive blood cultures without the presence of a central venous catheter are removed from the database (example – submit 60 +BCs on spreadsheet but only 10 have CVC answered Yes, then other 50 are removed)

9. Sample CLABSI Validation Steps, cont. • Iowa QIO randomly selects up to 4 candidate CLABSIs from the list remaining (example – select 4 from the remaining 10) • Iowa QIO sends list of 4 candidate CLABSIs from each hospital to the QIO Clinical Warehouse and the CDC • CDC looks to see if hospital reported any of the 4 candidate CLABSIs via NHSN • QIO Clinical Warehouse adds the 4 candidate CLABSIs to the other 15 charts (HF, PN, AMI, SCIP, ED/IMM)

10. CLABSI Validation Steps, cont. • CDAC sends chart request for all medical records to hospital • Hospital produces copies of all requested medical records and submits to CDAC within 30-day timeframe • CDAC abstracts candidate CLABSI charts for each hospital to determine if the patient had infection related to a central line and sends results to Iowa QIO • CDC sends results of whether any of 4 CLABSI candidates were submitted via NHSN to Iowa QIO

11. CLABSI Validation Steps, cont. • Individual validation score is computed for each of the 4candidate CLABSIs • CDC & CDAC report case CLABSI is 1/1 • CDC & CDAC report case CLABSI is 1/1 • CDC & CDAC report different results causes case to return to Iowa QIO for review with CDAC • CDC & CDAC final determinations do not match, then case is 0/1 • Individual validation scores will be combined with scores of other validation charts • Overall Validation Score <75% due to a CLABSI validation chart, hospital can appeal normally

12. HAI Validation TIPS • Start Now! First Deadline is May 1st! • Hospital must continue to submit CLABSI/CAUTI/SSI data to NHSN • NHSN entry data submission deadline vs. CLABSI/CAUTI validation spreadsheets deadline • If hospital has a waiver in place, they are not required to submit the CLABSI/CAUTI template • If hospital has no positive blood cultures for a particular quarter, they are required to submit the CLABSI and CAUTI templates by the quarterly deadline

13. Deadlines

14. Stacy Dorris, MBA, RHIA, CPHQ QI Specialist sdorris@qsource.org 901.273.2615