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titleIf a hospital already belongs to NHSN does that meet the requirement?

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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titleWhen and how do we join the NHSN Group for The Joint Commission?

In April 2024, The Joint Commission will e-mail the primary accreditation contact on file for the organization to determine the appropriate contact person to correspond with regarding the Joint Commission NHSN Group. After the contact has been identified, detailed instructions for joining the Group will be provided, and onboarding will take place May through June 2024.

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titleWho is the person that should join the NHSN group participation as I don't have access to NHSN data as its managed by the infection control dept.

The administrator of the NHSN group at your organization will be the person that will join The Joint Commission NHSN Group. 

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titleOur organization is exempt from ORYX Requirements; do we have to participate in The Joint Commission NHSN Group?

No; Exempt programs as indicated on the CY2024 ORYX Performance Measurement Requirements are currently excluded from NHSN participation requirement.

Per CMS' “Hospital-Acquired Condition Reduction Program Frequently Asked Questions Fiscal Year 2024” regarding program eligibility:

INCLUDES:

  • General acute care hospitals paid under the Inpatient Prospective Payment System (IPPS)

EXCLUDES:

  • Critical access hospitals

  • Rehabilitation hospitals and units

  • Long-term care hospitals (LTCH)

  • Psychiatric hospitals and units

  • Children’s hospitals

  • Prospective Payment System (PPS)-exempt cancer hospitals

  • Veterans Affairs hospitals

  • Short-term acute care hospitals in U.S. territories (American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands)

  • Religious nonmedical health care institutions

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Instructions for Joining The Joint Commission NHSN Group

Additional information pending

The CDC provides a guide on joining an NHSN Group, available via their website: https://www.cdc.gov/nhsn/pdfs/groups-startup/JoinGroup-current.pdf

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