HCP Influenza Vaccination Summary Reporting FAQs

Reporting Requirements: General

Q1. Which facilities are required to report healthcare personnel (HCP) influenza vaccination summary data through NHSN for the 2019-2020 influenza season?

Acute care facilities, inpatient rehabilitation facilities (IRFs), critical access hospitals, long-term acute care facilities, and prospective payment system (PPS)-exempt cancer hospitals are still required to report HCP influenza vaccination summary data through NHSN.

 

Q2. Can my facility still submit HCP influenza vaccination summary data through NHSN even if we are not required to do so by CMS?

Ambulatory surgery centers, inpatient psychiatric facilities (IPFs) and outpatient dialysis facilities are no longer required to report HCP influenza vaccination summary data through NHSN beginning with the 2018-2019 influenza season.  In August 2018, the Centers for Medicare and Medicaid Services (CMS) eliminated the HCP Influenza Vaccination Summary Measure from its quality reporting program for IPFs.  This change applies to both free-standing IPFs and IPF units that are located within hospitals.

However, please note that reporting these data may be required for certain facilities based on state or other reporting requirements. Facilities not required by CMS to submit data are welcome to voluntarily report HCP influenza vaccination summary data through NHSN for the 2019-2020 influenza season and beyond.  If these data are entered into NHSN by June 30, the data will be included in the regional-level data reports produced by NHSN for that influenza season (July 1 through June 30).

 

Q3. Where can I find information on the CMS final rule IRFs on reporting requirements for HCP influenza vaccination?

View CMS final rule for IRFs pdf icon[PDF – 1 MB]external icon (47905-47906).

 

Q4. Where can I find the operational guidance for IRFs to report HCP influenza vaccination summary data to fulfill CMS’s IRF Quality Reporting Program requirements?

View operational guidance for IRFs pdf icon[PDF – 150 KB].

 

Q5. Where can I find information on the CMS final rule for long-term acute care facilities (LTACs) on reporting HCP influenza vaccination data?

View CMS final rule for LTACs pdf icon[PDF – 1 MB]external icon (50857-50858).

Q6. Where can I find the operational guidance for LTACs to report HCP influenza vaccination summary data to fulfill CMS’s Long-Term Care Hospital Quality Reporting (LTCHQR) requirements?

View operational guidance for LTACs pdf icon[PDF – 150 KB].

 

Q7. Which HCP groups are required to be included in HCP influenza vaccination summary reports to CMS?

CMS requires reporting on influenza vaccination for three categories of HCP: employees, licensed independent practitioners (non-employee physicians, advanced practice nurses, and physician assistants), and adult students/trainees and volunteers aged 18 and over.  In other words, there is one category for all employees and two separate categories for non-employees.  Categories are mutually exclusive. NHSN includes space to enter vaccination data for other contract personnel, but these data are not currently required by CMS.  Facilities wishing to track influenza vaccination rates among other contract personnel can choose to use this optional reporting capacity.

 

Q8. Which data collection forms are facilities required to complete for reporting HCP influenza vaccination summary data to NHSN?

To report HCP influenza vaccination summary data, all facilities must complete two required forms: 1) HCP Safety Monthly Reporting Plan Form; and 2) HCP Influenza Vaccination Summary Form.

In addition to these two forms, dialysis centers that do not provide in-center hemodialysis are required to complete a third form before they can enter HCP influenza vaccination summary data.  This form is called the Home Dialysis Center Practices Survey.  The survey captures information about various topics such as surveillance practices, vaccination, and vascular access.

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 can help CDC examine the relationship of different vaccination program elements to facility-reported vaccination percentages.

 

Q9. Are the data reporting timeframes the same for the denominator and numerator of the HCP influenza vaccination measure?

The timeframes for the denominator and numerator of the HCP influenza vaccination measure 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 (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 season’s vaccine is available at a facility through March 31 should be reported in the numerator.  For example, if a healthcare worker was vaccinated in September, but then ceased to work at the facility before October 1, they would not be counted in the numerator or denominator data for that season.  However, if a healthcare worker was vaccinated in September and continued to work at the facility for at least one day from October 1 through March 31, they would be counted in both the numerator and denominator.  The reason the numerator and denominator cover different timeframes is to account for potential delays in vaccine availability.

 

Q10. What is the monthly reporting plan in NHSN and how is it used for HCP influenza vaccination reporting?

The monthly reporting plan indicates to the NHSN system which modules and protocols a user intends to follow for surveillance purposes in a specific month. The plan must be completed before data are entered for that month.  Monthly reporting plans must be created or updated to include HCP influenza vaccination summary reporting; i.e., HCP influenza vaccination must be “in-plan” for data to be shared with CMS.  Once the “Influenza Vaccination Summary” box is checked on a monthly reporting plan, the system will auto-check that same box on every monthly reporting plan throughout the entire NHSN-defined influenza season (defined as the 12 months from July 1 – June 30). Therefore, users need only enter one monthly reporting plan for each influenza season.

 

Q11. Do I need to report HCP influenza vaccination summary data each month?

Monthly reporting in NHSN is not required; 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, facilities are encouraged to update HCP influenza vaccination summary counts on a monthly basis so the data can be used to inform influenza vaccination activities at the facility.

 

Q12. How long are facilities able to edit HCP influenza vaccination summary data in NHSN?

Each facility’s HCP influenza vaccination summary data report must be entered into NHSN by May 15 for data to be shared with CMS.  Facilities can edit data any time after May 15, but these changes will not be sent to CMS.  In addition, the influenza season is defined by NHSN as July 1 to June 30, so changes after June 30 of an influenza season may not be used in state or regional reports created by CDC for that influenza season.

 

Q13. When is the deadline for submitting HCP influenza vaccination summary data to CMS?

To meet CMS reporting requirements, HCP influenza vaccination summary data reports must be entered into NHSN no later than May 15 for each influenza season.  Facilities can edit their data after May 15, but the revised data will not be shared with CMS.

 

Q14. I entered my HCP influenza vaccination summary data into NHSN. How can I confirm that my data were entered correctly and will be shared with CMS?

Facilities can review step-by-step instructions on how to confirm their data submission. View data verification instructions pdf icon[PDF – 300 KB].

 

Q15. I am using the CMS Line Listing to view the HCP influenza vaccination summary data for my dialysis facility. However, why is there not a row for the 2015-2016 influenza season?

A facility will not appear with a row in the line listing if it has not met Quality Incentive Program (QIP) criteria for the influenza season.  A facility has not met QIP criteria for HCP influenza vaccination reporting if: (1) it has not entered a monthly reporting plan or (2) it has not entered HCP influenza vaccination summary data.  Please check to make sure your facility has entered a reporting plan and entered summary data for the influenza season(s) not appearing in your CMS Line Listing output.

 

Q16. My long-term care facility entered HCP influenza vaccination summary data into NHSN. Will these data be sent to CMS?

Currently, there is no CMS requirement for long-term care facilities to report HCP influenza vaccination summary data to NHSN. Therefore, CDC will not share these data with CMS.  Long-term care facilities wishing to voluntarily report HCP influenza vaccination summary data to NHSN to improve tracking of HCP influenza vaccination in their facilities are encouraged to do so.

 

Q17. How will the data collected through the measure be used?

The tracking and reporting of HCP influenza vaccination status will help healthcare facilities identify and target unvaccinated HCP.  This may result in reduced morbidity and mortality related to influenza virus infection among HCP and patients.  HCP influenza vaccination summary data submitted through NHSN by May 15 will be reported by CDC to CMS.

 

Reporting Requirements: Acute Care Facility

Q18. Where can I find the operational guidance for acute care hospitals to report HCP influenza vaccination summary data to fulfill CMS’s IQR Program requirements?

The operational guidance for the IQR Program requirements for HCP influenza vaccination summary data reporting can be found at: View operational guidance for acute care facilities pdf icon[PDF – 300 KB].

 

Q19. Where can I find information on the HCP influenza vaccination summary reporting requirements for critical access hospitals (CAHs)?

Information can be found at: View guidance for CAHs pdf icon[PDF – 100 KB].

 

Q20. Are the reporting requirements for CAHs the same as acute care hospital requirements?

Yes, CAHs should follow the same reporting requirements that apply to acute care hospitals reporting HCP influenza vaccination summary data to NHSN.

 

Q21. Are CAHs required to submit separate vaccination reports for HCP working in outpatient units and inpatient units?

No.  Like acute care hospitals, CAHs should submit a single report on the vaccination status of HCP working in inpatient and outpatient departments of the facility that share the same CCN.

 

Q22. Should acute care facilities separate HCP working in the outpatient areas from those working in inpatient areas when reporting HCP influenza vaccination summary data?

CMS published a final rule in November 2018 eliminating the requirement for hospital outpatient departments to report HCP influenza vaccination summary data through NHSN beginning with the 2018-2019 influenza season.  On February 7, 2019, CMS and CDC issued guidance to clarify that this measure does not separate out HCP who only work in the inpatient or outpatient areas, or work in both:

“The IQR program Healthcare Personnel Influenza Vaccination measure is a facility-wide measure and does not separate out employees who only work in the inpatient or outpatient areas or work in both. Due to the burden of trying to separate out the counts for inpatient and outpatient, CMS allows facilities to collect and submit a single vaccination count to include all hospital-wide employees who meet the criteria, regardless of whether they work inpatient or outpatient. The hospital-wide or combined counts should be entered on one single influenza vaccination summary data form in NHSN. This includes all units/departments, inpatient and outpatient, that share the same CMS Certification Number (CCN) as the hospital and are affiliated with the acute care facility.”

Information can be found at: View CMS final rule for acute care facilitiesexternal icon.

 

Q23. How should acute care facilities report HCP influenza vaccination summary data?

Facilities should follow the guidance below when making determinations about which areas of the acute care facility to include when reporting HCP influenza vaccination summary data to NHSN as part of the CMS Hospital Inpatient Quality Reporting (IQR) Program:

• Include all inpatient units/departments of the acute care facility sharing the exact same CMS Certification Number [CCN] (100% identical) as the acute care facility, regardless of distance from the facility.
• Include all outpatient units/departments of the acute care facility sharing the exact same CCN (100% identical) as the acute care facility, regardless of distance from the facility.
• Exclude all inpatient and outpatient units/departments of the acute care facility with a different CCN (even if different by only one letter or number) from the acute care facility.

 

Q24. Why are free-standing IPFs required to enroll in NHSN, while IPF units having different CMS certification numbers (CCNs) from the acute care or critical access facilities usually do not need to do so?

IPF units do not need to enroll or activate the Healthcare Personnel Safety (HPS) Component unless their affiliated acute care or critical access facility is not already enrolled in NHSN or the IPF unit is not physically located within the walls of the affiliated acute care or critical access facility.  IPF units located within hospitals can simply be mapped as locations of the already-enrolled acute care or critical access facility.  Once the IPF unit is added as a location of the facility, the IPF unit-specific CCN is linked with that location. More information about how to map an IPF unit and add an IPF-unit specific CCN can be found at: View IPF Location Mapping pdf icon[PDF – 200 KB].

 

Q25. I am reporting HCP influenza vaccination summary data for an IRF unit that is physically located within our acute care facility. The IRF unit has the same CMS Certification Number (CCN) as the hospital except for an “R” (or “T”) in the third position. How should I report the IRF unit data in NHSN?

Influenza vaccination summary data for HCP working in this IRF unit should be reported separately from the acute care hospital summary data. You would need to add a separate monthly reporting plan for the IRF unit by checking “Influenza Vaccination Summary for Inpatient Rehabilitation Facility Unit(s)” under the box for “Healthcare Personnel Vaccination Module” on the monthly reporting plan screen.  Next, on the influenza vaccination summary data entry screen, use the dropdown box under the location field to select “IRF Unit(s)” before entering data.  HCP working in the IRF unit should not be counted in the summary report for the rest of the acute care facility unless they also work in other inpatient or outpatient units of the acute care facility between October 1 and March 31.

 

Q26. Why are free-standing IRFs required to enroll in NHSN, while IRF units having different CCNs from their acute care or critical access facilities usually do not need to do so?

IRF units do not need to enroll or activate the HPS Component unless their affiliated acute care or critical access facility is not already enrolled in NHSN or the IRF unit is not physically located within the walls of the affiliated acute care or critical access facility. IRF units located within hospitals can simply be mapped as locations of the already-enrolled acute care or critical access facility.  Once the IRF unit is added as a location of the facility, the IRF unit-specific CCN is linked with the facility so IRF unit data can be sent to CMS appropriately.  More information on how to add a CCN to an IRF unit can be found at: Adding CCNs to IRF Units pdf icon[PDF – 200 KB].

 

Q27. If my IRF unit has the exact same CCN as my acute care or critical access facility, do I need to report the IRF unit data separately from this facility?

No.  If the IRF unit CCN is 100% identical to the CCN of its acute care or critical access facility, then separate HCP influenza vaccination summary data reporting is not required by CMS.  Therefore, counts of HCP working in the IRF unit can be included in the total counts for the acute care or critical access facility. However, IRF units whose CCNs differ from the acute care or critical access facility CCN by even one letter or number – for example, having a “T” or “R” in the third position – must either be mapped as locations of the parent facility or enrolled as a separate NHSN facility, and their data must be reported separately.

 

Q28. There are multiple IRF units located within my facility. Should I report HCP influenza vaccination summary data separately in NHSN for each individual unit?

No.  The HCP influenza vaccination summary data of each individual IRF unit should be combined and submitted to NHSN as a single summary data report combining all CMS IRF units within the facility.

 

Q29. My health system administers influenza vaccination in an acute care hospital. Some HCP working in an IRF unit of the acute care facility that is part of our health system receives influenza vaccination in the acute care hospital. How should I categorize the vaccination status of these HCP?

Some health systems have a single group responsible for providing influenza vaccination to HCP working at several types of healthcare facilities and units that are a part of the system.  If these HCP receive influenza vaccination that is administered under the umbrella of the health system, then they should be documented as “receiving influenza vaccination at the healthcare facility” (#2 on the Healthcare Personnel Influenza Vaccination Summary report form) as part of the total counts for the IRF unit reporting in this facility.

 

Q30. I used to report data for my CMS inpatient psychiatric facility (IPF) unit that is located within an acute care facility. How should I report data for HCP working in this unit now that the CMS requirements for IPFs have changed?

HCP working only in the IPF unit should not be counted in the acute care facility vaccination summary report.  Vaccination status of these HCP does not have to be reported to NHSN for CMS purposes, although reporting may be required by the state or locality where the facility operates. However, HCP working in both the CMS IPF unit and in other units of the acute care facility should be included in the acute care facility vaccination summary report.

 

Q31. I am reporting from a LTAC that is physically within an acute care facility. How should I report the LTAC data in NHSN?

CMS reporting requirements for long-term acute care hospitals are separate from requirements for short-stay acute care hospitals.  Because the long-term acute care unit has its own CCN, it should have already enrolled in NHSN as a separate HOSP-LTAC facility. To fulfill CMS LTCHQR requirements, the LTAC must report HCP influenza vaccination summary data by adding a monthly reporting plan and submitting data separately through the enrolled NHSN LTAC facility.  HCP who work in this unit/facility would not be included in the influenza vaccination summary for the acute care hospital, unless they also work in the short-stay acute care facility.

 

Data Reporting

Q32. What identity proofing documents are required for the Secure Access Management Services (SAMS) process?

Users submit identity proofing documentation as part of the SAMS process, including a notarized identity verification form and supporting documents (driver’s license, passport, etc.). View more information about the SAMS process.

 

Q33. What CMS Certification Number (CCN) effective date should I list in NHSN for my facility?

The CCN effective date is the official date in which a facility first received its CCN from CMS.  For dialysis facilities, the effective date for your CCN should be the date of the CMS certification survey which resulted in the new CCN.  To update the CCN or CCN effective date, use the ‘Facility > Facility Info’ option on the left-hand navigation bar within NHSN.  At the top of the Facility Information screen, verify and update (if necessary) the CCN or CCN effective date in the appropriate data entry field(s). If any changes have been made, remember to click the ‘Update’ button at the bottom of screen.

 

Q34. Which NHSN component should I use to submit HCP influenza vaccination summary data for my facility?

All facility types should submit HCP influenza vaccination summary data to NHSN using the Healthcare Personnel Safety Component. This is true even for facilities that may report data primarily through other components, such as long-term care facilities and outpatient dialysis facilities.

 

Q35. What must I do to report to NHSN for the HCP Influenza Vaccination Summary Measure?

Facilities reporting to NHSN for the HCP Influenza Vaccination Summary Measure must follow the HCP Vaccination Module: Influenza Vaccination Summary Protocol pdf icon[PDF – 350 KB]

 

Q36. Where can I find training on collecting and reporting HCP influenza vaccination summary data to NHSN?

CDC has conducted training webinars on HCP influenza vaccination summary data reporting for multiple facility types. PowerPoint slides and recordings of the trainings are available on the CDC website: View archived trainings.

 

Q37. Does NHSN require influenza vaccination data to be reported for each individual healthcare worker?

No. Facilities are required to report summary rather than individual-level vaccination data.  Therefore, information such as employee-level demographic data is not required.

 

Q38. I logged into my NHSN facility, but I do not have the option to add a monthly reporting plan or enter HCP influenza vaccination data on the left-hand navigation bar. How can I enter my data?

This is most likely because your NHSN Facility Administrator has not conferred the proper user rights to you.  You should contact your Facility Administrator so they can confer the proper rights for you to view and enter data in the HCP Safety Component.

 

Q39. The HCP Influenza Vaccination Summary Form in NHSN defines the influenza season as July 1 to June 30. Does this mean that my facility is required to report on twelve months of data even though we do not administer influenza vaccine for all twelve months of the year?

No.  Although influenza may occur at any time of the year, you should report data for the reporting period specified in the NHSN protocol, which is October 1 through March 31 for the denominator, including all vaccinations given during the influenza season in the numerator.  The July 1 to June 30 time period is used by NHSN to clearly define the end of one influenza season and the beginning of the next influenza season.

 

Q40. Which month should I select on the monthly reporting plan for the HCP Vaccination Module?

You can select any month within the current influenza season.  Unlike the other NHSN components and modules, when “Influenza Vaccination Summary” is selected on one monthly reporting plan, the information is automatically updated on all reporting plans for the entire influenza season as defined by NHSN (July 1 to June 30).  Therefore, adding other reporting plans after the initial plan has been added for that influenza season is not necessary.

 

Q41. If my facility reported HCP influenza vaccination summary data for the 2018-2019 influenza season, do I need to create another monthly reporting plan for the 2019-2020 influenza season?

Yes, a monthly reporting plan must be completed once for each influenza season. You will not be able to enter or save HCP influenza vaccination summary data until you create a monthly reporting plan for that influenza season.

 

Q42. When trying to enter my HCP influenza vaccination summary data into NHSN, why do I receive an error message stating that a “plan does not exist with Influenza Vaccination Summary for Flu Season entered?”

You are receiving this message because you need to create a monthly reporting plan before you can enter HCP influenza vaccination summary data.  To add this plan, log into the HCP Safety Component of NHSN. Click “Reporting Plan” and then “Add” on the left-hand navigation bar.  Next, select a month and year from the drop-down menus; you can select any month and year during the current influenza season.  Then, check the box next to “Influenza Vaccination Summary” under the heading “Healthcare Personnel Vaccination Module” and click “Save.”  You will then be able to enter your HCP influenza vaccination summary data.

 

Q43. Can facilities review HCP influenza vaccination summary data that are entered into NHSN each month?

No.  Each time a user enters updated HCP influenza vaccination summary 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. Each HCP influenza vaccination summary data report entered into NHSN should be cumulative: for example, summary vaccination data entered at the end of November would include data from both October and November.  Facilities wishing to maintain monthly records should save their own copies of each data entry. Please note that monthly reporting in NHSN is not required for HCP influenza vaccination data; entering a single influenza vaccination summary report covering the entire influenza season will meet the minimum data requirements for NHSN participation.

 

Q44. How can I modify the HCP influenza vaccination summary data that have been entered in NHSN for my facility?

Go to “Flu Summary” and then “Find” on the left-hand navigation bar to identify data for the influenza season you wish to edit.  To edit data, first click “Edit” at the bottom of the HCP influenza vaccination summary data entry screen.  Next, you will proceed to enter the updated data.  Once this is complete, you must save the updated data by clicking the “Save” button at the bottom of the screen.  You should then see a message at the top of your screen confirming that your data have been saved.

 

Q45. Is each facility required to calculate vaccination percentages when using the Healthcare Personnel Vaccination module?

No.  Facilities will only need to enter the number of HCP that fall into each of the numerator and denominator categories.  The NHSN system will calculate vaccination coverage percentages for you.

 

Q46. My facility would like to track influenza vaccination for nurses. Is there a way we can track this group separately in NHSN?

Yes, you can use the Custom Field option in NHSN to create new fields for data that you would like to collect and analyze consistently.

 

Q47. When using the group function, why am I unable to view HCP influenza vaccination summary data for all influenza seasons?

You may need to change how your user rights are defined in order to view data for all influenza seasons. Please contact your Facility Administrator for more information about your user rights. Group Users can also define which influenza season data are available in NHSN. On the “Define Rights-Healthcare Personnel” page in NHSN (Facility > Define Rights), group users can select which influenza seasons will appear in the Group’s data.

 

Q48. Who do I contact for questions related to NHSN reporting of HCP influenza vaccination summary data?

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.  For example, an acute care facility sending a question to NHSN should include “HPS Flu Summary-Acute Care” in the e-mail subject line.

 

HCP Categories: General

Q49. What types of nurses are considered licensed independent practitioners?

All advanced practice nurses should be reported in the licensed independent practitioner category. Advanced practice nurses include nurse practitioners, nurse midwives, clinical nurse specialists, and nurse anesthetists.

 

Q50. What types of HCP are included in the “other contract personnel” category?

A suggested list of other contract personnel who might work in a healthcare facility is located in Appendix A of the HCP Vaccination Module: Influenza Vaccination Summary Protocol pdf icon[PDF – 350 KB].

 

Q51. Should employees who always work off-site or out-of-state, such as employees practicing telemedicine, be included in our HCP summary vaccination data reports?

No. Only HCP physically working at the healthcare facility for at least 1 day from October 1 through March 31 are included.

 

Q52. Should I count HCP who are not working with patients, but because of staff meetings, etc. are physically in the facility?

You should count HCP who meet protocol definitions and perform any work duty in the facility for at least 1 day from October 1 through March 31, regardless of clinical responsibility or patient contact.  For example, you should count HCP having official responsibilities in the facility such as attending regularly scheduled meetings or required training.  However, you would not need to count HCP who are not officially in the facility for work duties (e.g., coming into the facility for lunch) during the reporting period.

 

Q53. My healthcare system has two facilities, A and B. If an individual works at facility A for 1 day during the influenza season and works at facility B for 15 days during the influenza season, should I count them in the data for both facilities?

Yes, all employees, non-employee licensed independent practitioners, and non-employee adult students and volunteers should be counted at each facility where they physically work for at least one day from October 1 through March 31.  Therefore, you would include this individual in your influenza vaccination summary data reports both for facility A and for facility B.  These reports describe influenza vaccination rates among all HCP working at a specific facility, so all eligible HCP must be counted at each facility where they work.

 

Q54. There are three facilities within our healthcare system. Can I collect and enter a single report of HCP influenza vaccination summary data for our system since many of our staff members work at multiple facilities?

No, each of the system’s facilities need to be enrolled as separate facilities in NHSN and to report their HCP influenza vaccination summary data separately.  If an individual 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 they work.

 

Q55. Should I include an employee who starts working at my facility after October 1, or leaves their position after October 1, in my HCP influenza vaccination summary report?

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 or start dates, should be included in HCP influenza vaccination summary data reports.

 

Q56. In the protocol for collecting HCP influenza vaccination summary data, licensed independent practitioners are defined as physicians, advanced practice nurses, and physician assistants who are affiliated with the reporting facility but are not directly employed by it. What does it mean for HCP to be “affiliated with” a facility?

HCP who are affiliated with the healthcare facility are those who perform a work duty in the facility but are not directly employed by the facility (i.e., they do not receive a paycheck from the facility).  This would include non-employee HCP who come into the healthcare facility to round on patients, perform procedures, take facility-required trainings, or undertake other work duties.

 

Q57. How is a facility owner, particularly a physician owner, categorized for purposes of HCP influenza vaccination summary reporting?

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

 

Q58. Should physician fellows and residents be included in HCP vaccination summary reports?

Yes.  Physician fellows (post-residency) are categorized as licensed independent practitioners, unless they are paid directly by the facility, in which case they are employees. Residents and interns not on the facility’s payroll are categorized as adult students/trainees.

 

Q59. When are advanced practitioners counted as “employees” and when are they counted as “licensed independent practitioners”?

An “employee” is anyone on the payroll of or receiving a paycheck from the facility, regardless of their job duties.  Licensed independent practitioners working at the facility for at least 1 day from October 1 through March 31 who do not receive a paycheck directly from the facility should be counted in the “non-employee, licensed independent practitioners” category which includes physicians, advanced practice nurses, and physician assistants.  Post-residency fellows are also included in this category, unless they are paid directly by the facility, in which case they are employees.

 

Q60. Should I count a licensed independent practitioner who rarely comes into a facility during the influenza season?

This person would be included in the HCP influenza vaccination summary data report if they physically work in the facility for at least 1 day from October 1 through March 31.

 

Q61. Should I include licensed independent practitioners who work in the facility under a contract in my HCP influenza vaccination summary report?

Yes. It is necessary to track contracted physicians, advanced practice nurses, and physician assistants and report them as licensed independent practitioners.  Other types of contract personnel who do not meet the definition of a licensed independent practitioner can be reported in the optional “other contract personnel” category if desired. This category includes licensed or credentialed providers other than physicians, advanced practice nurses, and physician assistants who work under a contract with the reporting facility.

 

Q62. Are contractors such as housekeeping staff, environmental services staff, construction workers, etc. required to be included in HCP influenza vaccination summary reports?

No; reporting influenza vaccination summary data for these HCP is not required.  Non-licensed contract personnel can be reported in the optional “other contract personnel” category if desired.

 

Q63. Vendors or sales representatives occasionally come into my facility and may be present during surgeries or other patient care activities. Should we count these vendors in the optional other contract personnel category?

No.  Vendors are not considered to be HCP for the purposes of NHSN HCP influenza vaccination summary data reporting, since their primary role is to sell a product or service rather than to provide care or services to patients. Therefore, vendors should not be included in your summary data reports.

 

Q64. Should students who work a half-day shift for one day during the reporting period be included in HCP influenza vaccination summary data reports?

Yes.  Working any part of a day counts as working 1 day, so you would count these students since they worked at least 1 day from October 1 through March 31.

 

Q65. Should I count instructors who accompany students to a healthcare facility if the instructors do not otherwise work at the facility?

Yes, you would count these individuals in your HCP influenza vaccination summary data as adult students/trainees and volunteers since they are in the facility to provide instruction to the students/trainees.

 

Q66. High school students who are age 18 or older can 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 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.

 

Q67. How should we count ‘shadowers’ who visit our facility on a short-term basis to explore a possible career in healthcare? Would they be counted as students/trainees? Most of them are not enrolled in school when they visit.

You would not count shadowers who are touring the facility since they are not in the facility for a work-related or training-related purpose; however, CDC encourages these individuals to obtain influenza vaccination since they have potential exposure to infectious agents including influenza while in the facility.  The adult students/trainees and volunteers category should include only current medical, nursing, or other health professional students, interns, medical residents, or volunteers aged 18 or older who are affiliated with the facility for work or training purposes (e.g. clinical rotations).

 

Q68. Should clergy members be included in our facility’s HCP influenza vaccination summary reports?

Yes.  If they are physically in the facility for at least 1 day from October 1 through March 31, any unpaid personnel who are in the facility in a formal capacity (clergy member, board member, auxiliary member, etc.) are considered volunteers and should be counted in your summary vaccination report.

 

Q69. There are some HCP who work in the facility as part-time employees during the day and work as students by night. How should I classify these individuals?

The following hierarchy should be used to classify HCP at your facility: if a healthcare worker (HCW) who works in the facility is on payroll, they should be counted as an employee (even if they work as a student or volunteer at other times). If a HCW is not on the facility payroll, you should determine whether they meet the definition of a licensed independent practitioner. If not, you should finally determine whether the HCW is an adult student/trainee or volunteer. If none of those are the case, then you do not need to count that HCW in your HCP influenza vaccination summary report.

 

Q70. My healthcare system uses multiple payrolls. Should I count corporate employees of the facility who are paid through a corporate payroll in the employee category for HCP influenza vaccination reporting purposes?

Some healthcare systems use multiple payroll systems; for example, certain individuals within a particular facility may be corporate employees paid directly through a corporate payroll, while others at the facility are facility employees paid directly through a facility payroll.  For healthcare systems using multiple payroll systems, a facility would only count as employees those personnel who are paid directly through a facility payroll.  Corporate employees who are not paid directly through the facility payroll would not be counted in the employee category, although they could be counted in the licensed independent practitioner or other contract personnel categories if they meet NHSN protocol definitions for either group.  However, if a facility is part of a system that has only one payroll for the entire system, then each facility in that system would count all personnel on payroll in the employee category, if they physically work in that facility for at least 1 day from October 1 through March 31.

 

Q71. What does it mean when it is stated on the HCP Influenza Vaccination Summary Form that “denominators are to be calculated separately for the three required categories”?

The instruction to calculate the denominator data separately means that a facility is required to count and report the number of employees, licensed independent practitioners, and adult students/trainees and volunteers separately instead of reporting a total number of HCP working at the facility. That way, vaccination rates can be determined for each of the three groups.  For example, to determine the vaccination rate for employees, you would divide the number of employees who were vaccinated by the total number of employees who worked in your facility for at least 1 day from October 1 through March 31. You would then multiply this by 100 to obtain a percentage.

 

HCP Categories: Acute Care Facility

Q72. My acute care hospital owns several outpatient provider practices that are physically separate from the main hospital campus and have separate CCNs. Employees of these clinics are on the hospital’s payroll, so should I include them in HCP influenza vaccination summary report for the hospital?

No. Because the practices have separate CCNs, these employees should not be counted in HCP influenza vaccination summary reports for the acute care facility unless they also physically work in the acute care hospital for at least 1 day from October 1 through March 31.

 

Q73. My facility has an administrative building that is physically connected to the acute care facility by a skywalk. This building is only used for administrative duties and not patient care. Should I count HCP working in this building in the HCP influenza vaccination summary report for my acute care facility?

Yes, you should count HCP working in the administrative building, as it is considered part of the acute care facility.

 

Q74. Should HCP who are employees of a healthcare system (e.g., university employees), but who are not hospital employees, be included in the acute care facility HCP influenza vaccination summary report?

Non-hospital employees should only be included if they physically work in the acute care facility for at least 1 day from October 1 through March 31 and meet NHSN protocol definitions for either the licensed independent practitioner category or the adult student/trainee and volunteer category.  They would not be counted in the employee category since they are not on the hospital’s payroll.

 

Vaccination Status

Q75. If a HCW was vaccinated at their doctor’s office in August, and worked in the facility during the influenza season, should they be counted as vaccinated in our HCP influenza vaccination summary report?

Yes.  This HCW should be counted in the report for your facility, 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, their vaccination status would be counted as “unknown.”

 

Q76. What is considered 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 they received the influenza vaccine.  A note, receipt, vaccination card, etc. from the outside vaccinating entity stating that the HCW received the influenza vaccine at that location is also permitted. Verbal statements are not acceptable to document vaccination outside the facility for the purposes of NHSN HCP influenza vaccination summary data reporting.

 

Q77. If a HCW can only be reached by phone, and they state they were vaccinated elsewhere, how is this reported?

Their vaccination status is reported as “unknown” unless written documentation is provided. Verbal statements are not acceptable for the purposes of this reporting measure. However, this HCW could send an e-mail or mail a written statement attesting that they were vaccinated outside the facility.

 

Q78. My healthcare system includes numerous healthcare facilities. A HCW received influenza vaccine within our healthcare system; however, we are unable to identify the specific facility where they were vaccinated. Should this be counted as a vaccination received “at the facility” or “outside the facility”?

If the influenza vaccine was received at any facility within your larger healthcare system and you are unable to determine at which facility they were vaccinated, you can count the HCW as receiving vaccination “at the facility.”  Therefore, the HCW would not need to provide written documentation of this vaccination.  This only applies to attribution of the influenza vaccine for an individual HCW; facilities are expected to report separate numerator and denominator counts to NHSN for each individual facility in a healthcare system.

 

Q79. What conditions permit a HCW to be categorized as having a medical contraindication to influenza vaccination?

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 should be counted as having a medical contraindication to vaccination for purposes of HCP influenza vaccination reporting in NHSN.

 

Q80. 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 HCP vaccinated outside the reporting facility.

 

Q81. How should I categorize a volunteer who was offered influenza vaccination, but verbally refused vaccination and stated they 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 medical contraindications.

 

Q82. How do I categorize HCP who report that they have a medical contraindication but do not confirm that it is one of the two conditions defined as contraindications for NHSN reporting purposes?

They should be reported as “declined to receive the influenza vaccine.”

 

Q83. My facility offers the live attenuated influenza vaccine (LAIV4) to HCP who do not want to receive an injection. Are the acceptable medical contraindications the same for LAIV4 as for the inactivated influenza vaccine?

There are several different types of influenza vaccines available for use in adults; each vaccine has different precautions and contraindications for use. View Information on influenza vaccines.

HCP who have a medical contraindication to LAIV4 other than a severe allergic reaction to a vaccine component or history of Guillain-Barré Syndrome within 6 weeks after a previous influenza vaccination should be offered trivalent inactivated influenza vaccine (IIV3) or quadrivalent inactivated influenza vaccine (IIV4) by their facility, if available. If IIV3 or IIV4 is offered but declined because of aversion to an injection, the HCW would be categorized as “declined to receive the influenza vaccine.” Therefore, contraindications to LAIV4 that do not preclude receipt of injectable influenza vaccine are not acceptable medical contraindications for this measure.

 

Q84. How should I categorize a pregnant HCW who states that her healthcare provider recommended against influenza vaccination?

A HCW who does not receive the influenza vaccine because of pregnancy, or any medical reason other than the two allowable contraindications defined for this measure, should be categorized as “declined to receive the influenza vaccine.”

 

Q85. 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.”

 

Q86. How do I categorize a HCW who was granted a religious or personal belief exemption to influenza vaccination according to their 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.

 

Q87. 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 the HCP Vaccination Module 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. In some cases, HCP who are considered medically exempt from vaccination by the facility where they work will be counted as declining vaccination for the purposes of NHSN reporting.  Counting only HCP with specified conditions as having a medical contraindication to influenza vaccination ensures that HCP influenza vaccination data reported to NHSN can be compared across different facilities.

 

Q88. How should I categorize HCP who never came to a clinic or returned a declination form?

If you were unable to confirm a HCW’s influenza vaccination status for any reason, they should be counted in the “unknown” category.

 

Q89. If I use a survey to collect the numerator information for my facility’s HCP influenza vaccination summary report, how should persons who did not respond to the survey be counted?

If your facility decides to use a survey to collect vaccination status, HCP who do not respond to the survey should be counted in the “unknown” category.  The NHSN HCP influenza vaccination measure was not pilot-tested for use with a survey, and facilities are strongly encouraged to track influenza vaccination data from written records instead of using a survey.  Surveys should not be used to collect denominator data.