FY 2015 HAI Validation Requirements
Qsource
TN Department of Health
Qsource Data Reporting Assistance
Lesley Hays – Patient Care Improvement Manager
• Debra Bratton, QI Specialist
• dbratton@tnqio.sdps.org
• 901.273.2651
-Deadlines
• Carol Griffin, Programmer
• cgriffin@tnqio.sdps.org
• 901.273.2673
• Stacy Jowers Dorris, QI
Specialist
•sdorris@tnqio.sdps.org
•901.273.2615
-“Hot Lists”
-Abstraction
Questions
-Abstraction
Back-up
-IQR/OQR
-Data
Submission
- HAI
-CART
- NHSN
-QNet
• Deborah Scott, Infection
Prevention QI Specialist
• dscott@tnqio.sdps.org
• 901.273.2601
Discussion Points
FY 2015 Validation
 Background
▪ CLABSI, CAUTI, SSI – COLO/HYST
 CLABSI/CAUTI Validation
▪ Steps Involved
▪ Responsibilities
▪ Resources & Support
 Deadlines
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.
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
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
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)
Sample CLABSI Validation Steps
1. Identify candidate CLABSI events
2. Populate Blood Culture template
3. Submit Blood Culture template to CMS
Contractor (Iowa QIO) via QNet by quarterly
deadline
– QNet Security Administrator
4. Iowa QIO loads all data from the Blood Culture
template into large database
5. 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)
Sample CLABSI Validation Steps, cont.
6. Iowa QIO randomly selects up to 4 candidate
CLABSIs from the list remaining
(example – select 4 from the remaining 10)
7. Iowa QIO sends list of 4 candidate CLABSIs from
each hospital to the QIO Clinical Warehouse and
the CDC
8. CDC looks to see if hospital reported any of the 4
candidate CLABSIs via NHSN
9. QIO Clinical Warehouse adds the 4 candidate
CLABSIs to the other 15 charts (HF, PN, AMI,
SCIP, ED/IMM)
CLABSI Validation Steps, cont.
10.
11.
12.
13.
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
CLABSI Validation Steps, cont.
14. Individual validation score is computed for each
of the 4 candidate 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
15. Individual validation scores will be combined
with scores of other validation charts
16. Overall Validation Score <75% due to a
CLABSI validation chart, hospital can appeal
normally
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
Deadlines
Discharge Quarter
Q4 2012
HAI Template Due
May 1, 2013
HAI Data Due
May 15, 2013
Includes Healthcare Personnel Vaccine
Q1 2013
August 1, 2013
August 15, 2013
Q2 2013
November 1, 2013
November 15, 2013
Q3 2013
February 1, 2013
February 15, 2013
Stacy Dorris, MBA, RHIA, CPHQ
QI Specialist
sdorris@qsource.org
901.273.2615
April 10, 2013
The presentation and related material was prepared by Qsource, the Medicare Quality
Improvement Organization (QIO) for Tennessee, under a contract with the Centers for
Medicare & Medicaid Services (CMS), a federal agency of the Department of Health
and Human Services (HHS). Contents do not necessarily reflect CMS policy.
Qsource-TN-13-IPC.HAI.04>008