Frequently Asked Questions

About Mandatory Reporting

• Will facilities in states with mandatory reporting have to submit data twice: once to the state and once to CDC?
• How are patient data protected when they are reported to CDC?
• Can CDC provide support for all the facilities in states requiring reporting of healthcare-associated infections through NHSN?
• Who ensures that data reported in NHSN are accurate?
• Will data in NHSN be shared with CMS, IHI, JCAHO, or other organizations?

 

Will facilities in states with mandatory reporting have to submit data twice: once to the state and once to CDC?

No, the state, or entity authorized by the state to collect reports of healthcare associated infections, will view and analyze reports using a special function of the application referred to as “group functionality.” A group is created by a participating facility. Other facilities in the same state could join the group; all facilities would confer rights to the State or entity authorized to view and analyze reports. Facilities within the group cannot see each other’s data; only at the group level can data from the participating facilities be viewed and analyzed, as authorized by each facility. Facilities might collect more data than is required to be reported, and they can limit the authority of the group to view only data that are reportable. For example, a facility might conduct surveillance for surgical site infections associated with several different surgical procedures, but only authorize the group to view data on CABG.

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How are patient data protected when they are reported to CDC?

CDC is authorized under Title III, Section 301, Section 304, and Section 306 of the Public Health Service Act (42 USC 241, 242b, 242k, and 242m(d)) to collect data on healthcare-associated infections (HAIs). This assurance provides strict confidentiality for data that could identify an individual or institution. The data are collected for the purposes of quality improvement and program management only. Facilities can voluntarily release their own data to anyone they choose or grant access to a group (e.g., a state or accrediting entity for consumer choice purposes) to view and analyze the facility’s data. Even though a facility may choose to share data with a group, CDC is prohibited from sharing data with others. For more information visit: http://www.cdc.gov/ncidod/dhqp/nnis.html

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Can CDC provide support for all the facilities in states requiring reporting of healthcare-associated infections through NHSN?

CDC collaborates with State Health Departments and authorized entities to plan and prioritize support. CDC provides training for participation in NHSN; however, states have developed effective partnerships, such as that with their local Association for Professionals in Infection Control (APIC) and hospital associations, to improve training and customize reporting.

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Who ensures that data reported in NHSN are accurate?

States are working in collaboration with CDC to develop methods states can use for routine quality assurance and validation; however, facilities agree to follow specific methods, protocols, and definitions. Therefore, facilities should make their best effort to report only accurate data.

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Will data in NHSN be shared with CMS, IHI, JCAHO, or other organizations?

No, data collected in NHSN are held in confidence and used strictly for improving patient safety at the national level (http://www.cdc.gov/ncidod/dhqp/nnis.html). Facilities collecting data on process measures, such as those from the Surgical Care Improvement Project, will eventually be able to voluntarily upload those data electronically into NHSN. CDC collaborates with federal and national partners to create standards that will prevent duplication of efforts at the facility level. In aggregate, CDC analyzes and publishes surveillance data to estimate and characterize the national burden of healthcare-associated infections. To reduce the burden of reporting, harmonization of healthcare performance measures across national organizations is in progress, and for some measures has been achieved (i.e., pneumonia and bloodstream infections).

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