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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.

1. Catheter-associated Urinary Tract Infection (CAUTI) Outcome Measure;

2. Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure;

3. Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure;

4. Colon and Abdominal Hysterectomy Surgical Site Infection (SSI) Outcome Measure; and

5. Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia Outcome Measure.

Effective 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)

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)

• 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

• 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