CMS flu shot reporting will allow patients to compare hospital rates

New measure puts pressure on EH and IC

This influenza immunization season may be one of the most challenging for the nation's hospitals as they face a new requirement to track every employee, licensed practitioner, student and volunteer.

Beginning in January 2013, the Center for Medicare & Medicaid Services (CMS) will require hospitals to report their influenza immunization rates based on a standard measure. The information will be available to the public through the website,

The measure, which was certified by the National Quality Forum, counts employees, licensed independent practitioners (doctors, nurse practitioners and physician assistants) and students/trainees/and volunteers. Hospitals will report the percentage that received the vaccine, declined, or received religious or other exemptions. If an employee doesn't receive the shot but doesn't actively decline vaccination, they are included among the "unknown." (For more details, see story, below.)

The new measure will enable hospitals to compare their vaccination rates with other hospitals in their region or of a similar size. It also becomes one of several quality measures that consumers can use when selecting a hospital.

"The infection control and occupational health people will be under a certain amount of pressure because this will be publicly released data," says William Schaffner, MD, chairman of the Department of Preventive Medicine at Vanderbilt University in Nashville, TN, and past president of the National Foundation for Infectious Diseases.

At the same time, public reporting may bring greater clout and resources to infection control and employee health, he says.

Hospitals have already been preparing for greater scrutiny of their influenza immunization program. The Joint Commission influenza immunization standard (IC.02.04.01) became effective as of July 1, 2012. It requires hospitals to set annual goals and to work toward a vaccination rate of 90% by 2020.

An eye on the burden

How burdensome will the new reporting requirement be? That depends on the existing data collection systems related to human resources and employee health, says Melanie Swift, MD, medical director of the Vanderbilt Occupational Health Clinic.

To calculate the denominator for the measure, hospitals need to include individuals who have worked 30 days or more. For non-employees, such as students and volunteers, including only those who were on site for at least 30 days may be difficult, Swift says.

"An easier approach is to define the denominator of people who may have been in the institution for 30 days or more, and report vaccination status for that entire group," she says.

Many hospitals already have occupational health software to track immunizations. But those that need to update their technology may find some additional opportunities with the new rule, says Swift.

"For organizations who will be adding support to their occ health programs to track this, it's a good opportunity to look at the other things they need to track, such as TB testing and other vaccines, and be sure to build in the capacity to track and monitor these programs and services as well," she says. "This will require an investment of resources, but if done thoughtfully, you can gain value and efficiency by addressing more than just flu vaccine."

Measure designed for ease

Ease of reporting was a major consideration in the design of the measure, says Megan Lindley, MPH, epidemiologist with the National Center for Immunization & Respiratory Diseases at the Centers for Disease Control and Prevention.

Lindley and her colleagues conducted pilot tests of the measure at hospitals around the country and altered the specifications based on the feedback. For example, initially, the measure would have counted everyone who worked at least one day in the hospital.

"We just learned that was incredibly challenging for hospitals to track," she says.

Tracking contractors and vendors also was too difficult for some hospitals, she says. Hospitals may voluntarily report those vaccination rates.

The measure also sidesteps the need to collect written documentation. Employees can decline the vaccine through a written or online declination or verbally. And they are not required to show documentation if they state that they were vaccinated elsewhere.

"We found there were a lot of problems with requiring written declination," says Lindley. "Not all facilities use declination forms. For the measure now, verbal declination is acceptable."

The data will be reported through CDC's National Healthcare Safety Network (, which is the same surveillance system used to report hospital-associated infections.

Even with the efforts to make the new influenza immunization measure user-friendly, hospitals still will be ramping up their immunization programs and tracking efforts. Managers and hospital leadership will need to be onboard to ensure success, says Schaffner.

"I do believe that the occupational health service and infection control people will not be able to do this on their own," he says. "They're going to have to rely on the managerial structure of the institution to help them."

For example, managers will need to help with the follow up of employees who have not been vaccinated or declined, he says.

To mandate – or not?

It's a well-known adage that "what is measured gets done." With public reporting and greater scrutiny of flu vaccination rates, hospitals are looking for ways to boost their participation. A growing number of hospitals have opted for mandatory vaccination.

Last year, about 78% of hospital employees were vaccinated by early November, a rate that had almost doubled in five years. Yet the Joint Commission requires hospitals to work toward a HealthyPeople 2020 goal of 90% vaccination.

As a result, some hospitals have adopted controversial mandatory flu immunization policies as a condition of work. Whether or not your hospital uses a mandatory approach, it is important to address the reasons that employees choose not to be vaccinated, says Suzette Bramwell, DNP, RN, COHN-S, assistant professor of the College of Nursing at Brigham Young University in Provo, UT, who studied influenza vaccination and behavior change as part of her doctoral research.

Those reasons will differ and so you may need to tailor your message, she says. For example, employees with a fear of needles need to know about needleless options, such as the nasal version. Those without direct patient care, such as cafeteria workers, need to understand the potential benefits of vaccination.

Hospitals also may want to link the messages of their flu vaccination campaign to the overall mission of the organization, even using the same phraseology, Bramwell says. "Don't make it a totally different program," she says. "Show everyone how this fits with whatever you're trying to do every day."

The Veterans Health Administration is planning to use motivational interviewing to help promote influenza immunization. That technique, used for health issues such as smoking cessation and weight management, coaxes individuals to make changes by addressing their barriers and incentives to change.

"We're hoping that this proves to be a good alternative to mandating flu vaccines," says Ebi Awosika, MD, MPH, director of VHA's Employee Health Promotion Disease and Impairment Prevention program.

Editor's note: More information about the flu immunization tracking measure, including frequently asked questions, is available at

Breaking down the new flu shot measure

Developed by the Centers for Disease Control and Prevention, the following National Quality Forum measure will be used to report health care worker influenza immunization rates to the Centers for Medicaid & Medicare Services (CMS).

Description: Percentage of health care personnel (HCP) who receive the influenza vaccination.

Setting: Health care settings include acute care hospitals, nursing homes and other long-term care facilities, dialysis facilities, ambulatory surgery centers, outpatient clinics and physician offices.

Denominator Statement:Number of HCP who are working in the health care facility for at least 30 working days between October 1 and March 31 of the following year, regardless of clinical responsibility or patient contact.

Denominators are to be calculated separately for:

(a) Employees: all persons who receive a direct paycheck from the reporting facility (i.e., on the facility's payroll).

(b) Licensed independent practitioners: include physicians (MD, DO, MBBS), advanced practice nurses, and physician assistants only who are affiliated with the reporting facility who do not receive a direct paycheck from the reporting facility.

(c) Students/trainees and volunteers: include all students/trainees and adult volunteers who don't receive a direct paycheck from the reporting facility.

Numerator Statement: HCP in the denominator population who during the time from October 1 (or when the vaccine became available) through March 31 of the following year:

(a) received an influenza vaccination administered at the healthcare facility, or reported in writing (paper or electronic) or provided documentation that influenza vaccination was received elsewhere; or

(b) were offered but declined the vaccination; or

(c) were determined to have a medical contraindication/condition of severe allergic reaction to eggs or to other component(s) of the vaccine, or history of Guillian-Barré Syndrome within 6 weeks after a previous influenza vaccination; or

(d) Unknown: Persons with unknown vaccination status or who do not otherwise meet any of the definitions of the above-mentioned numerator categories.

Numerators are to be calculated separately for each of the above groups.

Exclusions: None.

Data Source: Medical or administrative records.

Denominator Codes:

1. Include all HCP in each of the three denominator categories who have worked at the facility between October 1 and March 31 for at least 30 working days. This includes persons who joined after October 1 or who left before March 31, or who were on extended leave during part of the reporting period. Work for any number of hours a day should be counted as a working day.

2. Include both full-time and part-time persons. If a person works in two or more facilities, each facility should include the person in their denominator.

3. Count persons as individuals rather than full-time equivalents.

4. Licensed practitioners who receive a direct paycheck from the reporting facility, or who are owners of the reporting facility, should be counted as employees.

5. The denominator categories are mutually exclusive. The numerator data are to be reported separately for each of the three denominator categories.

Numerator Codes:

1. Persons who declined vaccination because of conditions other than those specified in the 3rd numerator category above should be categorized as declined vaccination.

2. Persons who declined vaccination and did not provide any other information should be categorized as declined vaccination.

3. Persons who did not receive vaccination because of religious exemptions should be categorized as declined vaccination.

4. Persons who deferred vaccination all season should be categorized as declined vaccination.

5. The numerator categories are mutually exclusive. The sum of the four numerator categories should be equal to the denominator.