CMS Quality Reporting Programs Frequently Asked Questions
Where can I find guidance on what’s required to report to CMS for my facility type?
- More information on NHSN required reporting can be found here on the NHSN CMS Requirements webpage. This page provides operational guidance, reporting tips, and analysis explanation for specific types of reporting. An abbreviated list of reporting requirements by facility type can be found in the Reporting Requirements to CMS document. A more detailed list of reporting requirements and their associated deadlines can be found in CMS Reporting Requirements and Deadlines document. In addition, your local Quality Improvement Organization (QIO) or End-Stage Renal Disease (ESRD) Network can provide more information on what’s expected from your facility.
Where can I find the exact language of the CMS Reporting Program for my facility type?
- Facilities can find the exact language of the applicable CMS Reporting Program on the CMS website.
- CMS Hospital Inpatient Quality Reporting Program (IQR)
- CMS Hospital Outpatient Quality Reporting Program (OQR)
- CMS Long Term Care Quality Reporting Program (LTCHQR)
- CMS Inpatient Rehabilitation Facility Quality Reporting Program (IRFQR)
- CMS End-Stage Renal Disease (ESRD) Quality Improvement Program (QIP)
- CMS PPS-Exempt Cancer Hospital Quality Reporting Program (PCHQR).
- CMS Ambulatory Surgery Centers Quality Reporting Program
- CMS Inpatient Psychiatric Facility Quality Reporting Program (IPFQR)
Where can I find tips to make sure my NHSN facility is set up correctly to report to CMS?
- Tips on how to set up an NHSN facility to correctly report for CMS requirements can be found here on the NHSN CMS Requirements webpage.
I need some guidance on how to set up locations within my NHSN facility to comply with CMS reporting. Where can I find this information?
- Information on setting up locations within your NHSN facility can be found in the NHSN Locations Mapping document.
Where can I get a waiver to indicate that my acute care facility doesn’t fit the requirements to report to CMS?
- Please contact the CMS QIOSC to start the waiver process: IQR@hsag.com.
Where can I direct my questions regarding CMS payment and/or validation or any other questions not related to NHSN reporting?
- For questions regarding CMS payment and/or validation or any other questions not related to NHSN reporting, please consult your Quality Improvement Organization (QIO), ESRD Network, or CMS directly.
Do I need to confer rights or join a CMS group in order to share my data with CMS for reporting purposes?
- No. As long as the facility has entered their CMS Certification Number (CCN) in NHSN correctly, completed the monthly reporting plans, and entered data appropriately, data will be automatically sent to CMS for required reporting programs. QIOs, ESRD Networks, or State Health Departments may ask facilities to join their group so they can monitor and assist but data will be sent to CMS regardless of whether an NHSN facility is a member of such groups.
How does my data get from NHSN to CMS?
- Data entered into NHSN is sent to CMS according to facility CCN (CMS Certification Number). CMS provides CDC with a list of CCNs from which they expect to receive data for required reporting. CDC then takes that list and extracts the appropriate data from each NHSN facility with CCNs on the CMS list. Data ‘snapshots’ are sent to CMS periodically but the final data are ‘frozen’ at midnight on the day of the reporting deadline and sent to CMS the next business day (e.g., IPPS Acute Care Facilities’ data for Quarter 1 is frozen on August 15 and sent to CMS the next business day after the 15th).
Why do some facility types report rates and others report SIRs to CMS?
- Rates are provided to CMS when there has not been enough data entered for a specific reporting measure to calculate a baseline. Once enough data are gathered to build the appropriate SIR models for these location types, CDC will provide SIRs for these measures.
What are the data submission deadlines for CMS reporting?
- Data submission deadlines for CMS reporting vary by facility type. The complete list can be found here: Reporting Requirements and Deadlines in NHSN per CMS Current Rules.
Where can I see what data will be sent to CMS from my NHSN facility?
- Facilities can see the NHSN data that will be submitted to CMS using the special NHSN analysis output options for their specific facility type. To find the reports applicable to your facility type, log into your NHSN facility and go to Analysis > Output Options > CMS Reports > CDC Defined Output. Detailed guides for how to run and interpret the CMS reports can be found on the NHSN CMS Requirements webpage.
What if the data in CMS’ Hospital Compare don’t match the data that I had in NHSN?
- Please keep in mind that any data entered or modified within NHSN after the quarter freeze date will not be reflected in the data posted on Hospital Compare. Also, the frozen data from each quarter are aggregated to produce the measures on Hospital Compare. If you still have questions regarding the HAI data from your facility that is displayed on Hospital Compare, please contact the NHSN Helpdesk (NHSN@cdc.gov).
Where can I find information on how to validate my data?
- CDC currently offers guidance on how to validate 2012 CLABSI ICU data as well as 2013 CLABSI and CAUTI ICU, COLO and HYST SSI, and MRSA and CDI LabID event data within your facility. See Validation Toolkits.
CMS Certification Numbers (CCNs)
My CCN wasn’t validated when I enrolled my facility into NHSN. What do I do now and how will that affect my CMS reporting?
- If your CCN didn’t validate when you enrolled your facility into NHSN, you’ll need to add it into NHSN as soon as your NHSN facility is activated. The CCN can be added on the Facility Info page within NHSN. To do this follow these steps:
- After you’ve logged into your NHSN facility, click on Facility on the left hand navigation bar. Then click on Facility Info from the drop down menu. On the Edit Facility Information page, the very first section includes a space for the CMS Certification Number (CCN). Replace the N/A with your facility CCN. After confirming correct entry of your CCN, scroll to the bottom of the page and click the grey Update button. You should see a message at the top of the page confirming the update.
- If your CCN is not entered into NHSN by the next CMS reporting deadline, your facility’s data will not be sent to CMS.
- If your facility is new and you haven’t obtained a CCN yet, you can report your data as appropriate and add your CCN into your NHSN facility as soon as it becomes available to you.
I share a CMS Certification Number (CCN) with a sister healthcare facility(s). What happens to our data when it gets submitted to CMS?
- If more than one facility shares a CCN, the data from those facilities are rolled up by CDC and reported to CMS at the CCN-level. Remember: the NHSN Analysis Output Options only include data from your NHSN Facility OrgID; therefore, these numbers will differ from what you see on CMS sites.
My facility has been bought out or combined with another facility and I now have a different CCN. What should I do to make sure this change is captured within my NHSN facility?
- It’s important to contact NHSN to receive guidance on when to enter your new CCN into NHSN. Send an email to the NHSN Helpdesk (NHSN@cdc.gov) for help.
- Once it’s the correct time to add your new CCN into NHSN, follow the below steps:
- The CCN can be changed using these steps: After you’ve logged into your NHSN facility, click on Facility on the left hand navigation bar. Then click on Facility Info from the drop down menu. On the Edit Facility Information page, the very first section includes a space for the CMS Certification Number (CCN). Click the blue ‘Edit CCN’ hyperlink. On the Edit CCN Records pop up, click the grey Add Row button. Once the new row has been added, enter the new CCN and effective date. The Effective Reporting Quarter will automatically be populated based on the effective date you’ve entered. Confirm the CCN and effective date are correct and then click the grey Save button to save the update. You’ll see another pop up message saying your CCN has been created successfully. Click OK to close the pop up then click Close on the Edit CCN Records pop up to complete the change.
What training do I need to complete before I can submit my data?
- If you are a current NHSN user that has already completed the basic facility setup and data entry trainings, CDC recommends completing the HAI specific trainings that are specific to the types of reporting you’re completing each year in order to stay current with updated definitions and protocols. In addition, if you are a new user to the NHSN system, CDC recommends you complete the basic Facility Enrollment and Setup trainings as well as the Data Entry and Analysis trainings along with the HAI specific trainings.
Where can I find the training courses?
- HAI specific training courses can be found on each HAI specific page on the NHSN website. All training courses can also be found on the NHSN Training webpage.
- Please note: Training is not facility-type specific. Therefore, all facilities that are collecting CLABSI data can use the same CLABSI training materials.
My facility isn’t an acute care hospital. Do I complete the same trainings?
- Yes, trainings are specific to HAI type only. They are not facility-type specific. For example, all facilities reporting CAUTI data can use the same CAUTI training materials and NHSN protocols.
How often do I need to complete the NHSN trainings?
- CDC recommends completing the trainings once a year. Any definitional or protocol changes made within NHSN are effective as of January 1 so CDC recommends reviewing the NHSN protocols and training sessions at the beginning of each year.
SAMS (Secure Access Management Services)
Does each NHSN user need his/her own SAMS credentials?
- Yes. SAMS credentials are user specific NOT facility specific. Therefore, each individual user at a facility must have his/her own SAMS account and grid card. Furthermore, users that require access to more than one NHSN facility can use the same SAMS credentials for all NHSN access. To do this the user must use the same email address within each NHSN facility.
Do I need separate SAMS credentials to access other parts of NHSN such as the Healthcare Personnel Safety Component?
- No. SAMS credentials are user specific and NOT facility or component specific. Once a user has obtained SAMS credentials, he/she can access any component within NHSN that he/she has user rights to access.
For additional SAMS FAQs please see the SAMS NHSN User FAQ webpage.
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