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Effective July 1, 2024: Hospitals and Critical Access Hospitals already required through a CMS program to participate in NHSN will be required to participate in The Joint Commission NHSN Group.
Goals:
Improve timeliness of facility-level performance data available to hospitals and surveyors.
Provide Joint Commission facility-level performance data for use in the design and evaluation of improvement programs.
Minimize time and effort required to report data to The Joint Commission.
Topics Covered in this section:
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NHSN Frequently Asked Questions (FAQ) |
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Organizations were notified of the requirement to join The Joint Commission NHSN Group via the CY2024 ORYX Performance Measurement Requirements on October 5, 2023, as well as the November 2023 Perspectives® Newsletter. |
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Hospitals will need to join The Joint Commission NHSN Group to share data. Information on the process to join The Joint Commission NSHN Group will be distributed during late 2023 and early 2024. |
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Starting July 1, 2024, acute care hospitals and critical access hospitals will be required to allow The Joint Commission to access deidentified data on five CDC NHSN hospital-associated infection (HAI) measures from the NHSN application. These measures are all currently included in the CMS Hospital Value-Based Purchasing (VBP) Program and the Hospital-Acquired Condition (HAC) Reduction Program.
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Preventing healthcare-associated infections (HAIs) is a priority for The Joint Commission. Despite being largely preventable, an estimated 633,300 patients contract HAIs each year, and they result in about 72,000 annual deaths and have an estimated direct medical cost of $28.4 billion per year. The HAI infection rate increased significantly between 2019 and 2021, according to data from the Centers for Disease Control and Prevention (CDC). We have prioritized the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) system as a data source to evaluate patient safety and clinicial quality performance by Joint Commission-accredited hospitals. The majority of Joint Commission accredited hospitals already participate in NHSN as a requirement under CMS programs. There are several measures collected through NHSN applications that are currently included in the Accelerate PI dashboards. However, these data come from the publicly available CMS Compare website where the data can be 18-24 months old. Sharing NHSN data will allow us to include more recent data in Accelerate PI dashboards and identify quality improvement opportunities more efficiently |
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Facilities participating in the group can not see each other’s data. No PHI will be shared with Joint Commission. |
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No; Participation in the Joint Commission NHSN Group is not applicable for Freestanding Psychiatric Hospitals. |
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No; Exempt programs as indicated on the CY2024 ORYX Performance Measurement Requirements are currently excluded from NHSN participation requirement. |
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Instructions for Joining The Joint Commission NHSN Group |
Link to NHSN Guide to Joining a Group: https://www.cdc.gov/nhsn/pdfs/groups-startup/JoinGroup-current.pdf
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