ASC-8: What You Need to Know to Successfully Report

Please find below some of the most common questions ASCA has heard regarding enrollment, data collection and reporting for ASC-8: Influenza Vaccination Coverage among Healthcare Personnel. More information can be found on the NHSN web site.

Download NHSN Training Slides: HCP Vaccination Module Influenza Vaccination Summary.

NHSN Enrollment

Data Collection

Reporting Data

NHSN Enrollment

  1. Where do I start?
    CMS requires ASCs participating in the CMS Ambulatory Surgical Quality Reporting Program to report data collected by CDC via the National Healthcare Safety Network (NHSN). The NHSN is a secure, internet-based surveillance system maintained and managed by the CDC. To report ASC-8 through NHSN as required, someone from your ASC must register with NHSN. Click here for instructions.

  2. If my facility is already using NHSN, do I need to re-enroll?
    No. If your facility is already enrolled in NHSN, it does not have to be re-enrolled. Your NHSN Facility Administrator may simply activate the Healthcare Personnel Safety Component in NHSN.

Data Collection

  1. When is data collected for this measure?
    Data collection for ASC-8: Influenza Vaccination Coverage among Healthcare Personnel will take place for the influenza season between October 1, and March 31.

  2. What healthcare personnel must my facility include?
    Facilities must report vaccination data for three categories of healthcare personnel (HCP): employees on payroll (regardless of patient contact); licensed independent practitioners (who are physicians, advanced practice nurses, and physician assistants affiliated with the facility but not on payroll); and students, trainees, and volunteers aged 18 or older. All HCP physically working in the facility for at least one day or more between October 1 and March 31 should be counted. Data on vaccinations received at the facility, vaccinations received outside of the facility, medical contraindications, and declinations are reported for the three categories of HCP.

  3. If a healthcare worker (HCW) was vaccinated at his/her doctor’s office in August, should he/she be included?
    Yes. This HCW should be counted in the numerator, since influenza vaccine for a given influenza season may be available as early as July or August. The strict reporting period for the measure (October 1 through March 31) applies to the denominator. This HCW would be required to provide documentation of influenza vaccination and would be counted in the “vaccinated outside of the healthcare facility” category. If the HCW did not provide acceptable documentation as described below, his/her vaccination status would be counted as “unknown.”

  4. What is acceptable documentation for a HCW vaccinated outside of the healthcare facility?
    Acceptable forms of documentation include a signed statement or form, or an electronic form or e-mail from the HCW indicating when and where he/she has received the influenza vaccine, or a note, receipt, vaccination card, etc. from the outside vaccinating entity stating that the HCW received the influenza vaccine at that location. Verbal statements are not acceptable for the purposes of this measure.

  5. What conditions allow categorizing HCP as having a medical contraindication?
    Only HCP who have a severe allergic reaction to eggs or other components of the influenza vaccine or a history of Guillain-Barré Syndrome (a severe paralytic illness, also called GBS) within 6 weeks after a previous influenza vaccination can be reported as having a medical contraindication to vaccination with inactivated influenza vaccines.

  6. Is documentation required for medical contraindications or vaccine declinations?
    No. Documentation is not required for reporting a medical contraindication or a declination; therefore, verbal statements are acceptable for reporting these numerator categories. Documentation is only required for those vaccinated outside the facility.

  7. How should I categorize a volunteer who was offered influenza vaccination, but verbally refused vaccination and stated that he/she had an egg allergy with history of an anaphylactic reaction?
    The volunteer should be categorized as having a medical contraindication. Written documentation is not required for contraindications.

  8. How do I categorize HCP who report that they have a medical contraindication but do not confirm that it is one of the two defined by the measure?
    They are reported as “declined to receive the influenza vaccine.”

  9. What is the distinction between the “declined, deferred all reporting period” and “unknown” categories?
    HCP who deferred vaccination throughout the entire measure reporting period should be categorized as “declined,” because it is known they were offered the opportunity to be vaccinated. HCP should be categorized as “unknown” if their vaccination status was unable to be confirmed or they did not otherwise meet the criteria for the other numerator categories.

  10. How should I categorize HCP who decline vaccination because they are ill at the time the influenza vaccine is initially offered and then never have another opportunity to receive it?
    They are reported as “declined to receive the influenza vaccine.”

  11. How should I categorize a HCW who was granted a religious or personal belief exemption to influenza vaccination according to his/her facility’s policy?
    A HCW who declines to receive vaccination for any reason other than the two specified medical contraindications for the HCP Vaccination Module should be categorized as “declined to receive the influenza vaccine.” This is true even if your facility permits religious or philosophical exemptions for influenza vaccination.

  12. How should I categorize a HCW who received a medical exemption for influenza vaccination under his/her facility’s policy, which permits exemptions for conditions other than those specified in the NHSN protocol?
    A HCW who declines to receive vaccination for any reason other than the two specified medical contraindications for HCP influenza vaccination summary reporting should be categorized as “declined to receive the influenza vaccine.” This is true even if your facility permits medical exemptions for reasons other than those defined in the NHSN protocol.

  13. What types of nurses are counted as licensed independent practitioners?
    All advanced practice nurses should be included in the licensed independent practitioner category. Advanced practice nurses include nurse practitioners, nurse midwives, clinical nurse specialists, and nurse anesthetists.

  14. What types of HCP are included in the “other contract personnel” category?
    A suggested list of contract personnel who might work in a healthcare facility is located in Appendix A of the Healthcare Personnel Vaccination Module: Influenza Vaccination Summary Protocol.

  15. Should I count an employee who starts working at my facility after October 1, or leaves their position after October 1?
    Yes. All employees, non-employee licensed independent practitioners, and non-employee students and volunteers aged 18 and older who physically work at the facility for at least 1 day from October 1 through March 31, regardless of exact stop and start dates, should be counted.

  16. How is a facility owner, particularly a physician owner, categorized?
    Any owner, even a physician owner, is categorized as an “employee” and included in this measure if he/she is present in the facility for at least 1 day from October 1 through March 31.

  17. Should you count licensed independent practitioners who work in the facility under a contract?
    Yes. It is necessary to track contract physicians, advanced practice nurses, and physician assistants and report them as licensed independent practitioners. Other types of contract personnel who do not fall into the licensed independent practitioner category can be reported in the optional “other contract personnel” category, if desired.

  18. Are other licensed contract workers/non-employees such as nurses, technicians, therapists, etc. reported?
    Non-employee licensed or credentialed providers other than physicians, advanced practice nurses, and physician assistants who work under a contract with the facility are not required to be reported, but can be reported in the optional “other contract personnel” category, if desired.

  19. Are contractors such as housekeeping staff, environmental services staff, construction workers, etc. required to be included?
    No. Non-licensed contract personnel can be reported in the optional “other contract personnel” category, if desired.

  20. High school students who are age 18 or older are allowed to volunteer at our facility. Should these students be counted, or do we only report vaccination among health professional students?
    All students/trainees and volunteers aged 18 and over should be counted if they are physically in the facility for any part of at least 1 day from October 1 through March 31. It does not matter if the student is in high school, college, medical school, etc.

  21. Where can I find training on collecting HCP influenza vaccination summary data?
    CDC conducted live training webinars for facilities on the HCP Vaccination Module for the 2014-2015 influenza season in August 2014. PowerPoint slides and a recording of this training are available at: CDC’s Vaccines & Immunizations webpage.

Reporting Data

  1. I’ve enrolled and collected the data, now where do I go to report it?
    Facilities reporting to NHSN for the HCP Influenza Vaccination Summary Measure must follow the HCP Vaccination Module: Influenza Vaccination Summary Protocol. There is operational guidance for reporting this measure that can be found on the CDC's web site.

  2. When is the deadline for submitting data to CMS?
    To meet CMS requirements, the HCP influenza vaccination summary data report must be entered into NHSN no later than May 15 for each influenza season.

  3. Which month and year should I select on the monthly reporting plan for the HCP Vaccination Module?
    You can select any month within the current influenza season. Therefore, it is fine if you enter a single summary data report for one month (e.g., March). Unlike the other NHSN components and modules, when “Influenza Vaccination Summary” is selected on one reporting plan, the information is automatically updated on all reporting plans for the entire influenza season as defined by NHSN (which is July 1 to June 30). Therefore, adding other reporting plans after the initial plan has been added for that influenza season is not necessary.

  4. Which data collection forms are facilities required to complete for reporting HCP influenza vaccination summary data?
    In order to report HCP influenza vaccination summary data, staff members at each facility must complete two required forms: 1) the HCP Safety Monthly Reporting Plan form; and 2) the HCP Influenza Vaccination Summary form. The Seasonal Survey on Influenza Vaccination Programs for HCP is not required at this time. However, facilities are encouraged to complete this short survey, as the information will be very helpful for CDC.

  5. Are the data reporting timeframes the same for the denominator and numerator?
    The timeframes for the denominator and numerator are different. The denominator includes HCP who are physically present in the healthcare facility for at least 1 working day from October 1 through March 31, because October 1 through March 31 is the reporting period. The numerator timeframe begins “as soon as vaccine is available.” Therefore, vaccinations given any time during the influenza season from the time that vaccine is available at a facility through March 31 should be reported. For example, if a HCW was vaccinated in September but then ceased to work at the facility before October 1, he/she would not be counted. However, a vaccination given in September would be counted for a HCW who physically works at the facility for at least 1 day from October 1 through March 31. The reason the numerator and denominator cover different timeframes is to account for potential delays in vaccine availability.

  6. Do I need to report data each month?
    No. HCP influenza vaccination summary reporting in NHSN consists of a single data entry screen per influenza season, and this can be entered at any time during the influenza season, which is defined by NHSN as July 1 to June 30.

    Monthly reporting in NHSN is not required, and entering a single influenza vaccination summary report at the end of the reporting period for the influenza season will meet the minimum data requirements for NHSN participation. However, CDC/NHSN encourages that HCP influenza vaccination summary counts be updated on a monthly basis so they can be used at the facility level to impact influenza vaccination activities.

    Each time a user enters updated data for a particular influenza season, all previously entered data for that season will be overwritten and a new modified date will be auto-filled by the system. For example, aggregate vaccination data entered at the end of November would include summed data from both October and November. You should be entering cumulative data into NHSN, as the system does not add the numbers each month. Facilities wishing to maintain monthly records should save their own copies of each data entry.

  7. My facility is part of a multi-facility healthcare system that has one corporate payroll. Each facility has its own NHSN number, so how should each facility report?
    Each facility should report the total number of HCP who physically work in that facility. If a HCW physically works in multiple facilities in the healthcare system for at least 1 day from October 1 through March 31, this individual should be counted in the total number of HCP for each facility where he/she works. Questions should be sent via e-mail to NHSN@cdc.gov. Please include “HPS Flu Summary” in the subject line of the e-mail and specify your facility type, as this will help us to better assist you.