Measuring and Reporting Influenza Vaccination Coverage among Health Care Personnel in Your Long-Term Care Facility

Why measure vaccination coverage rates among your employees?

Tracking influenza vaccination coverage rates helps facilities gauge their progress towards meeting the Healthy People 2020 annual target goal of 90 percent for influenza vaccination among health care personnel (See Healthy People 2020 objective IID-12.9). High vaccination coverage rates helps ensure that long-term care HCP will be protected from influenza and residents will be less likely to acquire influenza from facility staff.

Currently, the Centers for Medicare & Medicaid Services (CMS) requires reporting of influenza vaccination coverage for workers in acute care hospitals as a part of the Inpatient Quality Reporting Program through the Centers for Disease Control and Prevention’s (CDC) National Health Care Safety Network, a web-based data reporting system using National Quality Forum (NQF) #0431. Each hospital’s influenza vaccination coverage among their health care personnel will be included as a quality measure on Medicare’s consumer-based Hospital Compare program.

What standardized quality measures are available for tracking health care personnel (HCP) vaccination?

The National Quality Forum (NQF) is a nonprofit organization that develops and promotes measurable health care quality standards. In July 2008, NQF gave time-limited endorsement to a measure for reporting influenza vaccination coverage among HCP. Following revision, the measure (NQF #0431) was fully endorsed by NQF in May 2012 and was incorporated into the CMS inpatient quality reporting program.

This measure requires facilities to collect data on the number of employees and certain nonemployee staff who work at the facility, and the number of vaccinated  employees and nonemployee staff who work at the facility, between October 1 and March 31 of each year.

Three mandatory categories and one optional category of HCP are counted:

• Employees (staff on facility payroll)
• Licensed independent contractors (physicians, advanced practice nurses, and physician assistants only who are affiliated with a facility but do not receive a direct paycheck from the facility)
• Adult students/trainees and volunteers (aged 18 and older)
• Optional – other contract personnel (direct care providers and providers of non-direct services, such as maintenance, information technology, or dietary food service staff)

Employees and nonemployees who have been vaccinated for influenza are also counted. For each category, the following numbers are reported:

• Influenza vaccinations
  • Vaccinated at your health care facility
  • Vaccinated elsewhere (requires that the HCP sign a note or an electronic form, or send an email that he/she was vaccinated, or provide proof of vaccination; verbal statements are not acceptable)
• Medical contraindications (accepted contraindications are severe allergic reactions such as anaphylaxis to eggs or another vaccine component or a history of Guillain-Barré syndrome within 6 weeks after a previous influenza vaccination; verbal statements are acceptable)
• Declinations (verbal statements are acceptable)
• Unknown vaccination status

Percentages of workers vaccinated are reported for each category of employees and nonemployees.

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Which facilities must report influenza vaccination coverage rates using NQF #0431?

• CMS currently requires acute care hospitals to collect influenza vaccination coverage data for workers, using NQF #0431. Data are reported via CDC’s National Health care Safety Network (NHSN). Additional information and training on reporting data for NQF #0431 through NHSN can be found at the CDC website.
• Starting in October 2014, CMS now requires long-term acute care hospitals, inpatient rehabilitation facilities, and ambulatory surgical centers to begin reporting influenza coverage rates among workers, using NQF #0431. Compliance with reporting may affect CMS payments to the facilities in 2016.
• Other CMS-certified health care providers, such as nursing facilities (nursing homes and skilled nursing), hospice, and home health may have to report vaccination coverage rates in the future, using NQF #0431.
• The Joint Commission’s Standard IC.02.04.01 for influenza vaccination of licensed independent practitioners and staff recommends (but does not require) the use of NQF #0431 to report influenza vaccination coverage data for workers in accredited programs, including nursing and rehabilitation centers, home care, and Medicare/Medicaid certification-based long-term care facilities. Even if use of this measure is not required at your facility, it is widely recognized and accepted for collecting and reporting HCP influenza vaccination coverage data.

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How to report influenza vaccination coverage among health care personnel in your facility

If your facility is required to report these data to CMS, someone at your facility should enter the data into the National Health Care Safety Network (NHSN). You must enroll in NHSN before you can enter data into the system. For most facilities, data must be entered by May 15 of each year in order to be transmitted to CMS.