Effective July 1, 2024: Acute care hospitals required to join Joint Commission NHSN Group

Beginning July 1, 2024, acute care hospitals with ORYX^® performance measurement requirements and that are required through a U.S. Centers for Medicare & Medicaid Services (CMS) program to participate in the U.S. Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) system will be required to join the Joint Commission NHSN Group. Participation in the Joint Commission NHSN Group will be optional for critical access hospitals where participation in CMS programs is not required.

The Joint Commission identified the NHSN system as a data source to evaluate patient safety and clinical quality performance by Joint Commission-accredited hospitals – many of which already participate in NHSN as a CMS program requirement.

How to join the Joint Commission NHSN Group

In April 2024 The Joint Commission will e-mail 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 identified, detailed instructions for joining the Group will be provided, and onboarding will take place May through June 2024.

Measures for the Joint Commission NHSN Group

Hospitals will grant The Joint Commission access to deidentified data on the following five CDC NHSN HAI measures from the NHSN application. Currently, all these measures are 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
5. Facility-Wide Inpatient Hospital-Onset Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure

The time period parameter will be set to begin with events that occurred in Q1 2021. The Joint Commission selected a look-back period because historical data more accurately depict trends and hospital performance over time.

The view options for patient-level data will be set for no patient identifiers. The Joint Commission will have access to facility-level data only. Hospital data will remain confidential and will not be shared with other Joint Commission-accredited hospitals. In accordance with NSHN Group rules, “A facility that joins a Group does not have access to any data from other facilities in the Group.” The Joint Commission does not plan to publicly report NHSN data.

The Joint Commission completed a rigorous evaluation process of technology components to ensure that privacy and security standards are met.

Information about the Joint Commission NHSN requirement was previously communicated in the November 2023 issue of Perspectives and the 2024 ORYX Performance Measures Reporting Requirements document. Additional information regarding the NHSN Group for The Joint Commission is available via the ORYX FAQs or the NHSN Group for The Joint Commission page.