May 4, 2020
TO: All Virginia Healthcare Facilities
FROM: M. Norman Oliver, MD, MA, State Health Commissioner
CC: VDH Healthcare-Associated Infections and Antimicrobial Resistance Program
Per the Code of Virginia (§32.1-35.1), requirements for reporting healthcare-associated infections (HAIs) align with the existing Centers for Medicare and Medicaid Services (CMS) reporting requirements. Data required to be reported to the National Healthcare Safety Network (NHSN) to meet CMS requirements should be shared with the Virginia Department of Health (VDH) through the NHSN system.
As you know, on March 22, 2020, CMS announced relief for clinicians, providers, hospitals, and facilities participating in quality reporting programs in response to COVID-19. As partners in public health and healthcare, we know that most facilities have redirected current resources to supporting the COVID-19 response and caring for affected patients. We understand that there is an immense burden placed on our healthcare facilities to not only care for patients, but also to report timely data to multiple entities.
Please consider that as facilities see an increase in their inpatient population, tracking HAIs becomes even more important. Surveillance of certain events related to COVID-19 can provide valuable information for HAI prevention efforts. While submitting HAI data for October 1, 2019 through December 31, 2019 (Q4) by the May 15 deadline and submitting HAI data for January 1, 2020 through June 30, 2020 (Q1-Q2) are optional per CMS, VDH strongly encourages facilities to continue to report the data they are able to collect accurately in accordance with NHSN surveillance protocols and definitions. We realize this may present some challenges, and we are available to answer any questions you may have. VDH still will be sending 2019 Q4 data cleaning reports to hospitals this week to review and verify data are accurate ahead of the May 15 reporting deadline. Q4 data submission will allow VDH to close out 2019 data and produce statewide annual statistics.
For questions related to how CMS may use these data, including scoring or payment questions, please reach out to the appropriate CMS help desk for further interpretation and guidance. Any questions regarding the impact of removing data from NHSN should be sent to the appropriate program’s help desk: CMS IQR (firstname.lastname@example.org) or HACRP (HACRP@mathematica-mpr.com).
Thank you for all you are doing on the front lines to prevent infections and provide care for all residents of Virginia.
- CMS Press Release (March 22, 2020): https://www.cms.gov/newsroom/press-releases/cms-announces-relief-clinicians-providers-hospitals-and-facilities-participating-quality-reporting
- CMS Memo (March 27, 2020): https://www.cms.gov/files/document/guidance-memo-exceptions-and-extensions-quality-reporting-and-value-based-purchasing-programs.pdf