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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.

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.


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.

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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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