HPS Personnel Annual Influenza Vaccination Summary

welcome to the healthcare Personnel safety component training session today we'll review the influenza vaccination summary of the healthcare Personnel vaccination module my name is Elisabeth Kile and I work in the nhsn vaccination unit I will be presenting information during this webinar today along with my colleague Julie seagull this presentation will cover several topics the steps on how to get started in the healthcare personal safety component will then be reviewed along with the surveillance and Reporting requirements for the module and the data reporting forms facilities will need to use the last segment of the presentation will outline the data analysis features of the application for the 2023 24 influenza season facilities that are part of certain CMS reporting programs will need to report annual Healthcare Personnel influenza vaccination summary data the data are reported through the healthcare personal safety component in nhsn on the nhsn leftand navigation panel find facility and then select add edit components please note that facilities must activate the healthcare personal safety component in nhsn to report annual influenza vaccination data only the nhsn facility administrator can activate a new component before a new component can be added users and facility administrators must upgrade to level three if this has not already been completed we'll review the steps for this upgrade later in the presentation the reporting period for the 2023 24 influenza season is from October 1st 2023 through March 31st of 2024 for facilities that are required to report the data by CMS they will need to submit one report covering the entire influenza season so in other words weekly or monthly reporting is not required the deadline to report annual Healthcare Personnel influenza vaccination summary data through the nhsn healthcare Personnel safety component is May 15th of 2024 NH HSN will then transmit the data to CMS we'll also reinforce these points as we go through the presentation and we'll review the data facilities will need to collect how to enter the data and how to run data analysis reports the next slides provide an overview of how to get started in the healthcare Personnel vaccination module of the healthcare Personnel safety component this slide demonstrates how to see if your facility has already activated the healthcare Personnel safety component a necessary step before you can report influenza data to check on this navigate to facility and add edit component to see if the box next to the healthcare Personnel safety component is checked as shown next to number one on the screenshot if it is then the component has already been activated if the facility administrator has also accepted the agreement to participate and consent as shown in number two here you are ready to report your data and make sure not to deactivate the healthare care or the long-term care component if you do need to activate the healthcare Personnel safety component facility administrators will log into the long-term care component or the healthcare Personnel safety component if a non- long-term care facility and navigate to facility and then add edit component facility administrators will then scroll to the components followed and then check the box next to healthcare Personnel safety an alert will pop up indicating that you must first Define the primary contact for the component and then click okay Enter the contact information on the next page for your Healthcare personal safety component primary contact note that this can be an existing NH HSN user after submitting and updating the information your facility administrator must return to the nhsn homepage and log in to the healthcare Personnel safety component to accept the agreement to participate and consent once rights are accepted your facility is ready to submit data for the healthcare Personnel safety component including annual influenza vaccination data now we'll review the specific reporting requirements ments for healthcare Personnel influenza vaccination data there are three required Healthcare Personnel categories one category consists of employees while the other two categories consists of non-employees one non-employee category is licensed independent practitioners and the other non-employee category includes adult students trainees and volunteers to be included All healthc Care personnel must be physically present in the facility for at least one work working day during the reporting period which is between October 1st through March 31st this slide shows a the top portion of the data collection form which lists the healthcare Personnel categories employees are defined as all persons receiving add direct paycheck from the healthcare facility regardless of clinical responsibility or patient contact the second Healthcare Personnel category consists of non-employee licensed independent practitioners specifically Physicians advanced practice nurses and physician assistants who are affiliated with the facility but are not on the facility's payroll and that's again regardless of clinical responsibility or patient contact this category also includes post residency fellows the third required Healthcare Personnel category consists of non-employee adult students trainees and volunteers who are aged 18 and older this is defined as medical nursing or other health professional students interns medical residents or volunteers as 18 or older that are affiliated with the healthcare facility but are not on the payroll regardless of clinical responsibility or patient contact this category consists of non-employee contract Personnel reporting for the category is optional at this time contract Personnel are defined as persons providing care treatment or services at the facility through a contract and 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 vaccination summary protocol for a suggested list contract Personnel if a facility decides to report contractor data you can note for which categories of personnel are included in their data by using the common function in nhsn which is noted later in the [Music] presentation vendors are also included in the other contact Personnel category regardless of clinical responsibility or patient contact therefore vendors providing care treatment or Services should be included in the category if they physically work in the facility for at least one day during the reporting period there are five Healthcare Personnel categories in the nhsn module and these are mutually exclusive this slide highlights the healthcare Personnel categories as they appear on the Forum the categories include influen of vaccinations received at the facility or elsewhere medical contraindications declinations and unknown vaccination status question number two on the influenza vaccination summary form covers Healthcare Personnel who received influenza vaccination either at the healthc Care Facility or elsewhere please note that there are two separate fields in the nhsn module the first field includes Healthcare Personnel who received received vaccination at the facility since vaccine became available this season question number three includes Healthcare Personnel who are vaccinated outside the facility since vaccine became available and provided a written report or documentation of vaccination acceptable forms of documentation include a signed statement or form an electronic form or email from the heal care worker or a note receipt or vaccination card from the outside vaccinating entity verbal statements are not acceptable for the module question four includes Healthcare Personnel who have a medical contraindication to the influenza vaccine for the measure for inactivated influenza vaccine accepted contraindications include a severe allergic reac action after a previous vaccine dose or 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 a vaccine component or history of GBS within 6 weeks after previous vaccination should be offered iiv by their facility if that's [Music] available therefore the medical contraindications stated above are the only acceptable cont indications for this module the fifth category is Healthcare Personnel who are offered and declined to receive influenza vaccine scene documentation is not required for reporting declinations and the sixth category is Healthcare personnel with unknown vaccination status or they did not meet any other criteria for the other numerator categories so now we'll review data entry I will turn things over to my colleague Julie seagull we will now go over entering data for the hcp influenza vaccination summary first we will go over how to navigate through nhsn you can access the activity homepage by clicking on the link listed on the slide you will then need to enter your Sam's username and password followed by your Sam's grid card numbers if you have questions or need assistance with using Sam's please contact the Sam's help desk tollfree by phone or by email using the information listed here once you are on the nhsn landing page facilities will need to select the healthcare Personnel safety component in the drop-down box this slide shows the HPS component homepage you will see that there is a navigation bar on the the left hand side of the web page which can be used to access different parts of the module this slide shows the steps facilities take to access the hcp influenza vaccination summary form first click on the vaccination summary then annual vaccination flu summary on your navigation bar select add next click continue to view the data collection form facilities with mapped irf units will see the screen when adding hcp influenza vaccination data the user must complete all Fields marked within asteris on this page influenza and seasonal are the default choices for vaccination type and influen subtype the user would then select the appropriate flu season in the drop down box for example if you are reporting data for the 2023 2024 influenza season you must select 2023 2024 in the dropdown box this is very important since data submitted under the incorrect influenza season will not be shared with CMS and will not fulfill their reporting requirements facilities can always contact nhsn if they are unsure of which influenza season is currently being reported the user should select the appropriate location from the drop- down box for example to report data for the long-term acute care hospital you would Select Hospital to report data for an inpatient Rehabilitation Unit that is part of your hospital you would select irf unit please note that to report data for both Hospital units and irf a summary report should be submitted for each facilities without an irf or ipf will see their screen when they go to report data the drop down for locations will be missing but otherwise it is the same screen this slide shows what the data entry screen looks like in the nhsn module the asteris 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 zero in a field if no hcp at the facility fall into that category the Comon box can be used to enter additional information which are usually side notes or reminders however the information cannot be analyzed within nhsn once the data has 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 15th reporting deadline will not meet the submission requirements or the CMS Quality Reporting program if you would like to edit or update your facility data simply click the edit button at the bottom of the screen for modifying existing data once you have completed your edits please be sure to save the updated data by clicking the save button that will appear at the bottom of the screen Please be aware that resubmission of data after the initial entry will overwrite pass data submission the date last modified shows when data were last entered and saved facilities can also add data via CSV upload they can do this by following the same pathway as described previously and then clicking on upload CSV CSV templates files and instructions can be found on our web page look under the CSV data import heading and under the annual Healthcare Personnel flu vaccination data subheading on the web page we will now go over the data analysis features for the hcp influenza vaccination summary to view data go to the generate data sets under analysis on the navigation bar click generate new and select okay when a message appears on your screen that says the current data sets will be overwritten are you sure you want to continue users should generate a new data set after each time they entered new data into the system next go to Output Options under analysis on the navigation bar you will see several folders on the screen irfs that are enrolled separately or freestanding irfs should click on the hcw vaccination module and influenza to view the default output click run report to see total numbers or summary counts percentages vaccination compliance figures and vaccination non-compliance figures irf units within acute care facilities should click on the hcw vaccination module influenza and irf influenza those units will need to click on an extra folder to view their data clicking on run report will display the default output for IP apps that are enrolled separately or freestanding IP apps click on the hcw vaccination module and influenza to view the default output click run report to see total numbers or summary counts percentages vaccination compliance figures and vaccination non-compliance figures ipf units within acute carecritical access hospitals should click on the hcw vaccination module influenza and then ipf influenza these units will need to click on an extra folder to view their data clicking on run report will display the default output for users wishing to modify the default analysis output they can click modify next to the report they wish to modify the modify function can be used for several things the user can export the data set into various analysis software such as Excel and SAS change the title of the modified output for later use and change the format of the output so that it can be viewed in a PDF or HTML format a facility also has the option to view output using variable labels an example is shown on the slide of how it looks to view the output using variable labels instead of viewing this by variable names which are used when running the output we will now go over how to confirm data entry after the data have been entered into nhsn users can verify that data have been saved correctly by running a report within the nhsn analysis feature this report can be found by facility type in a subfolder of the CMS reports folder by running this report the facility can review the hcp influenza vac vacination data by influenza season stratified by hcp category employees licens independent practitioners adult student trainees and volunteers and 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 popup locker and allow popups from. cdc.gov please refer to the link on this slide for the step-by-step guidance for running and interpreting this report for each facility type in addition to running the CMS line listing described on the previous slides 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 confirmed on the facility information screen within nhsn to get to the facility information screen C on facility then facility info on the leftand navigation bar first verify that the correct facility CMS Certification Number and CCN effective date have been entered effectively your CCN effective date should be the date your facility first received at CCN from CMS if you cannot obtain that date but it was prior to January 1st 2017 please use January 1st 2017 as the CCN effective date you also need to ensure that your facility is enrolled in nhsn as a cor correct facility type if your facility is not correctly enrolled please contact nhsn at cdc.gov for assistance this is very important as only facilities data from facilities enrolled as the correct facility type will be shared with CMS 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 correctly no further action is required on your part and 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 the next few slides will outline some resources that may be helpful to you the nhsn website contains links to the data collection forms tables of instructions for reporting data and training slides that facilities can use when reporting hcp influenza vaccination summary data through nhsn please refer to materials under the annual flu summary headings on the web page if you have any questions about nhsn please send a ticket to nhsn service now the new portal can be accessed at the link above if you do not have access to Sam's you can still email the nhsn helpes nhsn cdc.gov thank you so much for your time we wish you all a wonderful day