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Patient Safety Measure

In 2018 the Immunization Measures Category has been expanded to include additional Patient Safety Measures. The Medicare Beneficiary Quality Improvement Project requires that CAHs submit one influenza immunization measure and one ED measure: HCP (formerly OP-27): Influenza Vaccination Among Healthcare Personnel

HCP (formerly OP-27) is submitted annually through the National Healthcare Safety Network (NHSN) website.

Numerator

HCP workers who:

  • Received vaccination at the facility
  • Received vaccination outside of the facility
  • Did not receive vaccination due to contraindication
  • Did not receive vaccination due to declination

Denominator

Three categories (all with separate denominators) of HCP working in the facility at least one day between October 1 to March 31

  • employees on payroll
  • licensed independent practitioners
  • students, trainees and volunteers 18yo+

A fourth optional category is available for reporting other contract personnel

Acute care hospital inpatient and outpatient counts should be combined and submitted on a single influenza vaccination summary data form.  This includes inpatient and outpatient units/departments that:

  • Share the same CMS CCN as the hospital
  • Are affiliated with the specific acute care facility (such as sharing medical privileges or patients), regardless of distance from the acute care facility.

Facilities would not count HCP working in:

  • Separate outpatient satellite physician clinics (unless they also physically work in inpatient or outpatient units of the acute care facility for at least 1 day between October 1 – March 31)
  • Patient care units within the acute care hospital having separate CCNs (unless they also physically work in inpatient or outpatient units of the acute care facility for at least 1 day between October 1 – March 31)

Many more helpful resources on OP-27 can be found here.

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