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

The Hospital Associated Infection data will be pulled from NHSN, and you will not need to upload it manually to the DDSP site. 

Starting Effective July 1, 2024, acute care hospitals and critical access hospitals will be 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.

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.

Preventing healthcare-associated infections (HAIs) is a priority for The Joint Commission. Despite being largely preventable, an estimated 633,300 patients contract HAIs each year, and they result in about 72,000 annual deaths and have an estimated direct medical cost of $28.4 billion per year. The HAI infection rate increased significantly between 2019 and 2021, according to data from the Centers for Disease Control and Prevention (CDC).

We have prioritized the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) system as a data source to  evaluate to evaluate patient safety and clinical quality performance by Joint Commission-accredited hospitals. The majority of Joint Commission accredited hospitals already participate in NHSN as a requirement under CMS programs. There are several measures collected through NHSN applications that are currently included in the Accelerate PI dashboards. However, these data come from the publicly available CMS Compare website where the data can be 18-24 months old. Sharing NHSN data will allow us to include more recent data in Accelerate PI dashboards and identify quality improvement opportunities more efficiently

Facilities participating in the group can not cannot see each other’s data. No PHI will be shared with Joint Commission.

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)

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

• Rehabilitation hospitals and units

• Long-term care hospitals (LTCH)

• Psychiatric hospitals and units

• Children’s 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