The Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) is the nation’s most widely used health care-associated infection (HAI) tracking system. CDC is implementing a new national baseline for HAI’s that are reported to NHSN. On Saturday, December 10, 2016, NHSN users will be able to run standardized infection ratios for 2015 and 2016 under both the old baseline and the new baseline. Data for 2017 and forward will be available under the new baseline only.
A webinar has been scheduled for Wednesday, November 16, 2016, from 1:00 – 2:00 pm EST, and will include CDC providing an overview of the new HAI models as they relate to inpatient rehabilitation facilities (IRFs). Also to be discussed is the reason HAI data contained within the IRF preview reports may not align with the data in NHSN for the same target period. Registration is required to participate in the webinar; there is no fee to register.
As noted in the Rebaseline Timeline posted in the June 2016 National Healthcare Safety Network (NHSN) Newsletter, the Centers for Disease Control and Prevention (CDC) submitted standardized infection ratios (SIRs) to the Centers for Medicare and Medicaid Services (CMS), using the new 2015 baseline starting with 2016 Quarter 1 data. The inpatient rehabilitation facility (IRF) quality reporting program (QRP) preview reports that CMS provided on September 1, 2016, contained calendar year (CY) 2015 healthcare-associated infection (HAI) SIRs in accordance with the new NHSN baselines, based on nationally collected data from 2015. However, providers were unable to use NHSN to verify the accuracy of the HAI data contained within their preview reports for the Compare sites during the 30-day preview period established for this purpose.
As a result, CMS will begin publically displaying the NHSN data on the Compare sites for IRFs in the next quarterly refresh in spring 2017 instead of in fall 2016. Providers will have the chance to appropriately review their HAI data and inquire about data they believe to be incorrect. IRFs will receive preview reports in December 2016 for the data that will be displayed in spring 2017.
This change will affect the posting of quality performance data on the quality measure: NHSN Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure.
When the IRF Compare website is launched in fall 2016, the following quality metrics will be displayed:
- Percent of residents or patients with pressure ulcers that are new or worsened (short stay); and
- All-cause unplanned readmission measure for 30 days post-discharge from inpatient rehabilitation facilities.
To assist IRFs in understanding the use of the rebaselined data, and how to monitor their data using the new baseline, a document has been posted in the downloads section of the IRF Quality Public Reporting web page.