Upcoming ASCQR influenza vaccination process of care measure: What ASCs need to know

Ambulatory surgery centers participating in the Ambulatory Surgical Center Quality Reporting program will soon be required to begin reporting data for the process of care measure #ASC-8: Influenza Vaccination Coverage among Healthcare Personnel.

Beginning Oct. 1, 2014, through March 31, 2015, ASCs certified by the Centers for Medicare & Medicaid Services, regardless of specialty or case, will report data for this added measure to the Centers for Disease Control and Prevention via their National Health Safety Network (NHSN), a secure, Internet-based surveillance system.

In 2012, a quality reporting program for ASCs, known as the Hospital Outpatient Prospective Payment/Ambulatory Surgical Center Payment Systems and Quality Reporting Program, was developed and finalized by CMS. The goal was to develop outcome and process measures to determine payment to facilities that treat Medicare patients.

In 2012, four outcome measures and one process of care measure were adopted for the CY 2014 payment determination. Two additional measures (web-based) were added for the CY 2015 payment determination, bringing the total to seven quality measures. For the CY 2016 payment determination, the previously adopted claims-based and web-based measures were adopted and one process of care measure was added. In the 2014 final rule, three additional web-based measures were adopted for the CY 2016 payment determination.1 

ASCs that do not meet program requirements, which include reporting of quality measure data for the ASCQR program, may receive a 2 percent reduction in their ASC annual payment update.2

Measure #ASC-8 was introduced in the 2014 final rule as a result of a recommendation by the Advisory Committee on Immunization Practices. According to CDC, ACIP's recommendation reads as follows: "ACIP recommends that all healthcare personnel (HCP) and persons in training for healthcare professions be vaccinated annually against influenza. Persons who are infected with influenza virus, including those with subclinical infection, can transmit influenza virus to persons at higher risk for complications from influenza. Vaccination of HCP has been associated with reduced work absenteeism and with fewer deaths among nursing home patients and elderly hospitalized patients. Although annual vaccination is recommended for all HCP and is a high priority for reducing morbidity associated with influenza in healthcare settings, national survey data have demonstrated that vaccination coverage levels are only approximately 70 percent. This is well below the Healthy People 2020 goal of 90 percent for HCP influenza vaccination."3

Reporting definition

The reporting definition for process of care measure #ASC-8 is as follows:

Healthcare personnel (HCP) - Facilities must report vaccination data for three categories of HCP: employees on payroll; licensed independent practitioners (who are physicians, advanced practice nurses, and physician assistants affiliated with the hospital 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.1

NHSN enrollment

CDC/NHSN provides step-by-step guidance, training resources as well as contact information to guide facilities through the reporting process.4

•    If facilities have never utilized the NHSN data collection system, they must enroll and participate in specified components such as HCP influenza vaccination. Facilities may choose to voluntarily participate in various other components if desired.

•    Facilities that are already enrolled in NHSN need to activate the HCP – Influenza component.

•    NHSN has key roles for facility staff including the "facility administrator" and "users." There is only one "facility administrator" and he/she is responsible for enrolling the facility in NHSN. Enrolling with NHSN has to be done prior to October 1 in order to ensure that your facility has been successfully added to the system. The NHSN "facility administrator" will add other users and perform other functions if necessary that are of an NHSN nature only. This is not to be confused with the ASC administrator.

•    Additional users may be given administrative rights but are typically staff members who can add, view and analyze data.

Reporting influenza vaccination summary data

NHSN provides a summary protocol, which is a facility guide to collecting and reporting influenza vaccination summary data for the HCP vaccination module.5

It outlines reporting requirements and specifications which include the following:

•    Data collection forms
•    Denominator categories and notes
•    Numerator categories and notes
•    Data sources
•    Methodology
•    Calculations for data analyses in NHSN
•    Table of instructions
•    Key terms

Reporting data, as required by CMS in order to receive the maximum annual payments, adds yet another layer of responsibility to already overburdened ASCs. However, as infection prevention efforts improve, the federal government, state and local health departments and accreditation organizations continue to hold facilities accountable for providing patients with a safe and healthy environment. While ASCQR is yet another step in the complex process, it is a critical one for ASCs and the industry.

Phenelle Segal, RN, CIC, is the founder, owner and president of Infection Control Consulting Services (www.iccs-home.com). She has more than 30 years of experience in the infection prevention and control industry, with extensive experience in the ambulatory surgery center industry.


Centers for Medicare & Medicaid Services Ambulatory Surgical Center Quality Reporting Program Quality Measures Specifications Manual. Found on the internet at: https://staging.qualitynet.org/dcs/BlobServer?blobkey=id&blobnocache=true&blobwhere=1228774248217&blobheader=multipart%2Foctet-stream&blobheadername1=Content-Disposition&blobheadervalue1=attachment%3Bfilename%3DASC_Specs_Manual_v4.0.pdf&blobcol=urldata&blobtable=MungoBlobs

ASCQR Program Reference Checklist. Found on the internet at: http://qualitynet.org/dcs/BlobServer?blobkey=id&blobnocache=true&blobwhere=1228890319605&blobheader=multipart%2Foctet-stream&blobheadername1=Content-Disposition&blobheadervalue1=attachment%3Bfilename%3DASC_2014_RefChcklst_060214.pdf&blobcol=urldata&blobtable=MungoBlobs

NHSN Surveillance for Healthcare Personnel – ASCs. Found on internet at: http://www.cdc.gov/nhsn/ambulatory-surgery/hcp-vaccination/

NHSN Healthcare Personnel Safety Component Healthcare Personnel Vaccination Module Influenza Vaccination Summary Ambulatory Surgery Centers http://www.cdc.gov/nhsn/PDFs/training/HCP-flu-Vaccination-Summary-Reporting-ASC-Training-slides.pdf

HEALTHCARE PERSONNEL SAFETY COMPONENT PROTOCOL. Healthcare Personnel Vaccination Module: Influenza Vaccination Summary. Available on the internet at: http://www.cdc.gov/nhsn/PDFs/HPS-manual/vaccination/HPS-flu-vaccine-protocol.pdf

Copyright © 2022 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.


Patient Safety Tools & Resources Database

Featured Learning Opportunities

Featured Webinars

Featured Whitepapers

Featured Podcast