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REGULATORY REVIEW


ASC-8 Requirements What you need to know to report successfully BY KARA NEWBURY


In 2012, the Centers for Medicare & Medicaid Ser- vices (CMS) confirmed that ASCs that want to remain compliant with Medicare’s


national quality reporting program and avoid payment penalties down the line would need to begin reporting a mea- sure on Influenza Vaccination Coverage Among Healthcare Personnel (now des- ignated as ASC-8) in 2015. When that decision was announced, that deadline seemed too far away to worry about, but now is the time to become familiar with the reporting requirements related to this new measure, register to report and begin collecting data.


NHSN Registration CMS requires ASCs participating in its Ambulatory Surgery Center Qual- ity Reporting (ASCQR) Program to use the National Healthcare Safety Network (NHSN) to report the portion of the information that the Centers for Disease Control and Prevention (CDC) collects, which includes the ASC-8 data. NHSN is a secure, Internet-based surveillance system maintained and managed by the CDC. To report ASC-8, facilities that are


currently not participating in NHSN must first select a facility administrator to enroll their facility in the system. The facility administrator is the only per- son who can add, edit or delete rights to facility data to other users. It is impor- tant to note that this is also the only per- son who can re-assign the role of facil- ity administrator to another user. Once the facility administrator has been assigned, that person must start a five-step enrollment process. This pro- cess can take several weeks, so ASCs that are not already enrolled in NHSN are advised to register immediately.


20 ASC FOCUS JANUARY 2015


ASC professionals can find instruc- tions for registering with NHSN at www.cdc.gov/nhsn/ambulatory-surgery/ enroll.html: ■


Step 1: Read the NHSN Facility Administrator Guide found on the CDC web site.





Step 2: Agree to the NHSN Rules of Behavior and register the ASC with NHSN using the ASC’s CMS Certi- fication Number (CCN).





Step 3: Review and accept the Secure Access Management Ser- vices (SAMS) Rules of Behavior and register with SAMS. Within one to three days of successful online reg- istration, the security administrator receives a SAMS ‘Identity Verifica- tion Request’ email, which includes an identity verification form that must be endorsed by a notary public and faxed to the CDC. Within 30 days of the SAMS


approval email, a SAMS grid card is delivered to the security adminis- trator’s home address via US mail. This card provides the necessary





information for access to NHSN to complete enrollment.





Step 4: Log in to SAMS using the SAMS grid card, select NHSN Enrollment


and submit required


NHSN forms, including facility con- tact information.


Step 5: Immediately after submit- ting the required NHSN forms, the security administrator should receive an NHSN email with the subject “NHSN facility enrollment submitted.” Using the above NHSN email, open, print and sign the con- sent form. Ensure two signatures are on the form and fax to CDC. Within three business days, receive NHSN email, with subject ‘NHSN enroll- ment approved.’ If your facility is already enrolled


in NHSN, it does not have to be re- enrolled. Your NHSN facility admin- istrator may simply activate the Healthcare Personnel Safety (HPS) Component in NHSN. The HPS Com- ponent is the only component neces- sary for reporting health care person- nel (HCP) influenza vaccination data.


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