Surveillance and Technology
Concurrent Education Session - 60 minutes
Consistent HAI reporting is essential for public reporting. Additionally, CMS’ pay for performance programs, hospitals are subject to quality measure validation including HAI reported through the NHSN. Validation may result in loss of funds if a lack of appropriate HAI reporting is identified. NHSN HAI surveillance definitions require interpretation of clinical documentation by IPs, which can lead to inconsistent HAI reporting.
This session will describe how an 8-hospital system, ranging in size from 185-1,100 beds, prepares for CMS audits—having recently experienced four HAI validations with 100% compliance, uses an inter-rater reliability (IRR) process to overread 100% of NHSN reported events, and shares learnings with all IPs across our system.
This session will share the process for preparing for external entity validation and will explain how they performed IRR, how they reached consensus on accurate reporting and consistent interpretation of NHSN definitions, and how they disseminated NHSN guidance across our system. Finally, we will describe how we leverage technology to stay connected at our multiple sites and to engage IPs in learning.