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Effective July 1, 2024: Acute Care Hospitals already required through a CMS program to participate in NHSN will be are required to participate in The Joint Commission NHSN Group.
Schedule
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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.
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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.
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May–June 2024: Hospitals join the Joint Commission NHSN group and accept the
Confer Rights Template.
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Joining The Joint Commission NHSN Group
Contact hcooryx@jointcommission.org to request instructions on how to join The Joint Commission NHSN Group.
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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Organizations were initially notified of the requirement to join The Joint Commission NHSN Group via the CY2024 ORYX Performance Measurement Requirements on October 5, 2023, as well as the November 2023 Perspectives® Newsletter. We include a reminder to joint the group in within the ORYX requirements annually. |
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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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| In April 2024, The Joint Commission e-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 was identified, detailed instructions for joining the Group will was provided via email, and onboarding took place May through June 2024.||||
Newly accredited HCOs should joint the NHSN Group by the first calendar quarter after receipt of their accreditation decision letter. Instructions to join The Joint Commission’s Center for Disease Control and Prevention (CDC) |
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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. |
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The Hospital Associated Infection data will be is pulled from NHSN, and ; you will do not need to upload it manually to the DDSP site. |
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Hospital Associated Infection data are currently displayed on the Centers for Medicare and Medicaid Services (CMS) Care Compare website. The Joint Commission does not currently plan to publicly report this data on Quality Check. |
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Effective July 1, 2024, acute Acute care hospitals are 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.
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Facilities participating in the group cannot see each other’s data. No , and no PHI will be shared with Joint Commission. |
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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:
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:
Effective July 1, 2024, joining the Joint Commission NHSN Group does not apply to entities that are exempt from ORYX requirements: EXCLUDES:
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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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