NHSN Frequently Asked Questions (FAQ)

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.

Hospitals also need to join The Joint Commission NHSN Group to share data.

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)
National Healthcare Safety Network (NSHN) Group, including the group ID and joining password,
can be found within your organization's secure Joint Commission Connect® site. Continuous
Compliance>ORYX Performance Measurement Resources and Related Links>Instructions to Join
The Joint Commission NHSN Group

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.

The administrator of the NHSN group at your organization is the person that joins The Joint Commission NHSN Group. 

If you are uncertain who your NHSN group administrator is, we suggest contacting your Quality and/or Infection Control/Prevention department.

Organizations confer rights / give permission for The Joint Commission to access the 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 is pulled from NHSN; you do not upload it manually to the DDSP site. 

Hospital Associated Infection data are 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.

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.

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 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 cannot see each other’s data, and no PHI will be shared with Joint Commission.

No; Participation in the Joint Commission NHSN Group is not applicable for Freestanding Psychiatric Hospitals.

Participation in the Joint Commission NHSN Group is optional for CAHs. CAHs may participate in other programs for which they submit the HAI measures. For example, the HAI measures are optional in MBQIP, a CMS CAH quality improvement program. https://www.ruralcenter.org/sites/default/files/2023-02/MBQIP-Measures.pdf

CAHs are not required to report the IQR NHSN measures because they are not paid under the Inpatient Prospective Payment System.

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

Instructions for Joining The Joint Commission NHSN Group