IRF and LTCH Public Reporting Update - CDC & NHSN Rebaseline Guidance

As noted in the Rebaseline Timeline posted in the June 2016 National Healthcare Safety Network (NHSN) Newsletter, the CDC submitted standardized infection ratios (SIRs) to CMS using the new 2015 baseline starting with 2016 Q1 data.  The Inpatient Rehabilitation Facility (IRF) and Long-term Care Hospital (LTCH) Quality Reporting Program (QRP) Preview Reports that CMS provided on September 1, 2016 contained calendar year (CY) 2015 healthcare-associated infection (HAI) SIRs in accordance with the new NHSN baselines based on nationally collected data from 2015. However, providers were unable to use NHSN to verify the accuracy of the HAI data contained within their preview reports for the Compare sites during the 30-day preview period established for this purpose.  

Consequently, CMS will begin publically displaying the NHSN data on the Compare sites for IRFs and LTCHs in the next quarterly refresh in spring 2017 instead of in fall 2016.  Providers will have the chance to appropriately review their HAI data and inquire about data they believe to be discrepant. IRFs and LTCHs will receive preview reports in December 2016 for the data that will be displayed in spring 2017.

This change will affect the posting of quality performance data on the following quality measures: 

• NHSN Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure (IRFs and LTCHs)
• NHSN Central-Line Associated Bloodstream Infections (CLABSI) Outcome Measure (LTCHs only)

When the IRF and LTCH Compare websites are launched in fall 2016, the following quality metrics will be displayed:

IRFs—

• Percent of residents or patients with pressure ulcers that are new or worsened (short stay)
• All-cause unplanned readmission measure for 30 days post-discharge from Inpatient Rehabilitation Facilities

LTCHs—

• Percent of residents or patients with pressure ulcers that are new or worsened (short stay)
• All-cause unplanned readmission measure for 30 days post-discharge from long-term care hospitals

To assist IRFs and LTCHs in understanding the use of the rebaselined data and how to monitor their data using the new baseline, a document has been posted in the downloads section of the IRF Quality Public Reporting and LTCH Quality Public Reporting webpages.