Voluntary or State Mandated Enrollment

Eligibility Criteria

Facilities participating in NHSN must meet the following criteria:

• Be a bona fide healthcare facility in the United States, e.g., be listed in or associated with a facility that is listed in one of the following national databases: American Hospital Association (AHA); Centers for Medicare and Medicaid Services (CMS); or Veteran’s Affairs (VA).
• Have email addresses for NHSN users and high-speed Internet connections on the computers they will use to access NHSN.
• Comply with secure access control requirements of the system.
• Be willing to follow the selected NHSN component protocols exactly and report complete and accurate data in a timely manner during months when reporting data for use by CDC.
• Be willing to share such data with CDC for the purposes stated above.
• Be able to provide written consent for participation in NHSN by a member of the facility’s chief executive leadership (e.g., Chief Executive Officer).

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Data Collection and Reporting Requirements for Participation

Once enrolled in the NHSN, each facility must:

• Use the NHSN Internet-based data entry interface and/or data import tools for reporting data to CDC.
• Successfully complete an annual survey for each component selected.
• Successfully complete one or more modules of the component selected. Successful completion requires the following:
  • For the selected component, submit a reporting plan each month to inform CDC which, if any, of the modules will be used for that month. Data for at least one module must be submitted for a minimum of six months of the calendar year to maintain active status.
  • Adhere to the selected module’s protocol(s) exactly as described in the NHSN Manual during the months when one or more NHSN modules are used. This includes using surveillance methodology appropriate for the module and as described in the protocol.
  • Report adverse events/exposures and appropriate summary or denominator data as required for the module(s) indicated on the reporting plan to CDC within 30 days of the end of the month.
  • For those months when the Healthcare Worker Exposure module is followed and no exposures are reported, confirm that none occurred.
  • Pass quality control acceptance checks that assess the data for completeness and accuracy.
• NHSN facilities must agree to report to state health authorities those adverse event outbreaks that are identified in their facility by the surveillance system and about which they are contacted by CDC.
• Failure to comply with these requirements will result in withdrawal from NHSN. Such facilities will be offered the opportunity to download their data before being withdrawn. Six months after withdrawal, a facility may apply for re-enrollment into NHSN.

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Required Training

Before enrolling in or using the system NHSN requires that each of its users, including the facility administrator, is thoroughly trained. The training requirements differ depending on the role of the NHSN user.

See the following roles to review the training requirements:

Facility Administrator

• Read the NHSN Facility Administrator Enrollment Guide [PDF - 496 KB] October 2011.
• View the NHSN Enrollment & Facility Start-up training session and read the corresponding slidesets
• View all training sessions and read slidesets & manuals relating to the NHSN methodology of data collection and data entry for the type of facility enrolling and/or enrolled component:

Trainings:

• Patient Safety Component
• Healthcare Personnel Safety Component
• Biovigilance Component

Documents:

• NHSN Facility Administrator Enrollment Guide [PDF - 496 KB] October 2011.
• NHSN Manual: Patient Safety Component Protocols
• NHSN Manual: Healthcare Personnel Safety Component [PDF - 356KB]
• NHSN Manual: Biovigilance Component Protocol Hemovigilance Module [PDF - 785 KB]
  Guidelines and procedures for monitoring hemovigilance.
  June 2011.

NOTE: The person designated as the NHSN Facility Administrator is the only person who can enroll a facility in NHSN or reassign the role of Facility Administrator. This person will also have the ability to confer rights to groups, that is, entities with which your hospital wants to share some/all of its data (e.g., state or county health department, corporate headquarters). Therefore, this role should be given to an individual who has the authority to perform these functions within your hospital’s organizational structure. In many hospitals participating only in the NHSN Patient Safety Component, this will likely be the lead Infection Preventionist (IP). In that case, the NHSN Facility Administrator may also be designated as the NHSN Patient Safety Primary Contact Person. For facilities participating only in the NHSN Healthcare Personnel Safety Component, the person responsible for the occupational health functions is a good candidate for both NHSN Facility Administrator and NHSN Healthcare Personnel Safety Primary Contact Person. For facilities participating only in the NHSN Biovigilance Component, the transfusion medicine specialist or laboratorian collecting and entering data would be a good candidate for both NHSN Facility Administrator and Biovigilance Primary Contact Person. For facilities participating in more than one NHSN Component, the NHSN Facility Administrator should be a person with authority across the involved departments.

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User (other than Facility or Group Administrator)

User Start-up Guide [PDF - 433 KB] October 2011
A step-by-step start-up guide for NHSN Users who are not Facility Administrators or Group Administrators.

• Read the User Start-up Guide.
• View training sessions and read slidesets and manuals, applicable to their task.

Trainings:

• Patient Safety Component
• Healthcare Personnel Safety Component
• Biovigilance Component

Documents:

• NHSN Facility Administrator Enrollment Guide [PDF - 496 KB] October 2011.
• NHSN Manual: Patient Safety Component Protocols Guidelines and procedures monitored in the Patient Safety Component includes instructions for completing data collection forms.
• NHSN Manual: Biovigilance Component Protocol Hemovigilance Module [PDF - 785 KB]
  Guidelines and procedures for monitoring hemovigilance.
  June 2011.

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Group Administrator

• Read the NHSN Group Administrator Guide [PDF - 1.32MB]
  A step-by-step start-up guide for forming a group in NHSN.
  June 2009.
• View all training sessions and read slidesets and manuals relating to the NHSN methodology of data collection for the type of group nominated

Trainings:

• Patient Safety Component
• Healthcare Personnel Safety Component
• Biovigilance Component

Documents:

• NHSN Facility Administrator Enrollment Guide [PDF - 496 KB] October 2011.
• NHSN Manual: Patient Safety Component Protocols Guidelines and procedures monitored in the Patient Safety Component includes instructions for completing data collection forms.
• NHSN Manual: Healthcare Personnel Safety Component [PDF - 356KB]
• NHSN Manual: Biovigilance Component Protocol Hemovigilance Module [PDF - 785 KB]
  Guidelines and procedures for monitoring hemovigilance.
  June 2011.

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System Requirements

The following recommended system requirements were developed to ensure the best use of the key features of the NHSN which demand high processor performance, such as Java graphical interface, Internet audio / video streaming, professional 3D graphics, multimedia, data analysis, graphical data visualization.

It is the responsibility of the healthcare facility to choose the specific microcomputer brand and model to purchase.

Minimum System Requirements

• 1 GHz equivalent or greater Intel Pentium III processor
• 512MB of RAM
• Windows XP
• Email account
• High-speed internet access (greater than 200Kbs)
• 500 MB available disk space
• Microsoft Internet Explorer 6 or higher
  NOTE: The only internet browser that can be used with NHSN is Microsoft Internet Explorer. Do not use another browser when accessing NHSN

Additional System Recommendations

• Computer
  2 GHz processor - Intel Pentium IV, or AMD
  K6/Athlon/Duron family, or compatible processor recommended
  512MB of RAM
  Sound card
  Speakers or headphones (optional)
  CD-ROM or DVD drive (optional)
  Hard disk 40 GB
  
• Monitor
  17" Super VGA (800 X 600) or higher resolution video adapter and monitor
• Operating System (OS)
  Windows XP/ Windows 2000 / Windows Vista / Windows 7
• Printer
  Laser Printer

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