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titleHow do we confirm we have joined the Joint Commission NHSN Group - is there a letter?

After rights are conferred, users should see a confirmation stating “Conferred Rights saved successfully for group”. When the template is accepted, data sharing is complete. If additional action is needed, we will reach out to you directly with more information.(CDC NHSN memberships page - Screenshot included below)

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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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titleWe are a Critical Access Hospital; are we required participate in The Joint Commission NHSN Group?

Participation in the Joint Commission NHSN Group is optional for CAHs. CAHs may participate in other programs for which they submit the HAI measures. For example, the HAI measures are optional in MBQIP, a CMS CAH quality improvement program. https://www.ruralcenter.org/sites/default/files/2023-02/MBQIP-Measures.pdf

CAHs are not required to report the IQR NHSN measures because they are not paid under the Inpatient Prospective Payment System.

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titleOur organization is exempt from ORYX Requirements; do we have to participate in The Joint Commission Who is required to join the 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:

INCLUDESEffective July 1, 2024, joining the Joint Commission NHSN Group is mandatory for acute care hospitals with ORYX requirements who are also required to participate in NHSN for a CMS program.

REQUIRED:

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

EXCLUDES

Effective July 1, 2024, joining the Joint Commission NHSN Group is optional for hospitals who are not required to participate in NHSN for a CMS program:

OPTIONAL:

  • Critical access hospitals (CAH)

  • Rehabilitation hospitals and units

  • Long-term care hospitals (LTCH)

  • Psychiatric hospitals and units

  • Children’s hospitals

  • Military Treatment Facilities

  • Veterans Administration Hospitals

  • Free-standing Children’s Hospitals

  • Indian Health / Tribal Hospitals

Effective July 1, 2024, joining the Joint Commission NHSN Group does not apply to entities that are exempt from ORYX requirements:

EXCLUDES:

  • Freestanding Psychiatric Hospitals

  • Inpatient Rehabilitation Facilities (IRFs)

  • Long Term Acute Care Hospitals (LTACHs)

  • 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

Instructions to join The Joint Commission’s Center for Disease Control and Prevention (CDC)
National Healthcare Safety Network (NSHN) Group

Additional information pending

The CDC provides a , including the group ID and joining password,
can be found within your organization's secure Joint Commission Connect® site. Continuous
Compliance>ORYX Performance Measurement Resources and Related Links>Instructions to Join
The Joint Commission NHSN Group

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Please follow the instructions provided by the CDC 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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