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Effective July 1, 2024: Acute Care Hospitals already required through a CMS program to participate in NHSN will be required to participate in The Joint Commission NHSN Group.

Sign-Up Milestones and Troubleshooting

The following table provides the timeline of sign-up tasks.

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April 2024

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Hospitals will receive a survey via e-mail to indicate their appointed
NHSN facility administrator and provide contact information for that
individual. This survey should be completed no later than April 29,
2024.

May 2024

An e-mail with NHSN Group joining instructions will be sent to the
designated NHSN facility administrator; instructions also will be posted
on the hospital’s Joint Commission Connect extranet site or the ORYX
Performance Measurement Resources page.

May–June 2024

Hospitals will join the Joint Commission NHSN group and accept the
Confer Rights Template.

July 1, 2024

Enrollment in the Joint Commission NHSN Group must be complete.


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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Expand
titleWho is required to join the NHSN Group?

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

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