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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.

Schedule

  • April 2024: Hospitals received a survey via e-mail to indicate their appointed
    NHSN facility administrator and provide contact information for that
    individual. The deadline to complete that survey was April 29,
    2024.

  • May 2024: An e-mail with NHSN Group joining instructions was sent to the
    designated NHSN facility administrator; instructions also were posted
    on the hospital’s Joint Commission Connect extranet site or the ORYX
    Performance Measurement Resources page.

  • May–June 2024: Hospitals 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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titleIf a hospital already belongs to NHSN does that meet the requirement?

Hospitals will also need to join The Joint Commission NHSN Group to share data. Information on the process to join The Joint Commission NSHN Group was distributed 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 mailed 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 was identified, detailed instructions for joining the Group will be was provided via email, and onboarding will take took 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 is the person that will join joins The Joint Commission NHSN Group. 

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titleHow will we submit NHSN data...in the DDSP portal?

Data will be entered directly into NHSN, and organizations will Organizations confer rights / give permission for The Joint Commission to access this datathe data they are already entering into NHSN. Organizations will not need to enter this data in the DDSP.  

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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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