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Frequently Asked Questions

CMS Hospital Inpatient Quality Reporting Program

National Healthcare Safety Network (NHSN) Enrollment Requirements

  1. Does a hospital need to sign a new Centers for Medicare and Medicaid (CMS) Notice of Participation form to submit data to NHSN?
    No, hospitals participating in the Hospital Inpatient Quality Reporting Program (Reporting Program), formerly known as the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program, do not need to complete a new Notice of Participation. Hospitals that want to participate in the Reporting Program for the first time must complete the Notice of Participation. NHSN has a separate consent process to submit data.
  2. Why does the final rule not require critical access hospitals to meet these requirements?
    Critical access hospitals are not required to participate in the Hospital Inpatient Quality Reporting Program. They may voluntarily report data for publication on the Hospital Compare website.
  3. Does a hospital already enrolled in NHSN need to submit another NHSN consent form?
    Soon: When the updated NHSN Agreement to Participate and Consent form is available, current users of NHSN will receive an email with instructions for completion and submission of the updated consent form. This will be distributed mid-December 2010.  NHSN affords its participants  an Assurance of Confidentiality that restricts the use of the data  to the stated purposes. Several new purposes of the surveillance system have been added, one of which enables reporting of HAI and prevention practices adherence data via NHSN to CMS . Signing the NHSN Agreement to Participate and Consent form indicates the hospital’s acknowledgment of this purpose and therefore allows CDC to provide CMS the data required for participation in  the Hospital Inpatient Quality Reporting Program.
  4. Where does a hospital send a completed NHSN consent form?  Should the form be sent to a Quality Improvement Organization (QIO)?
    No, the signed NHSN Agreement to Participate and Consent form should not be sent to a QIO. The hospital will receive notification during the enrollment process with instructions as to where the form should be returned. For hospitals already enrolled in NHSN, an email with instructions for completion and submission of the updated consent form will be distributed in mid-December 2010.
  5. If a hospital does not have an adult/pediatric intensive care unit (ICU) or neonatal intensive care unit (NICU), is the hospital required to report data via NHSN?
    If a hospital has no ICU beds, the hospital must submit the required notice that indicates it has no ICU beds. NHSN enrollment is not required for hospitals participating in the Hospital Inpatient Quality Reporting Program in 2011 that do not have ICU beds. The required notification form, timing, and where to submit the form will be announced as decisions are finalized. (Effective 11/3/2010)

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Update CMS Certification Number (CCN)

  1. Will NHSN  be supplying CMS with a list of CMS Certification numbers (CCN) reporting to NHSN? How does a hospital update a CCN or name with NHSN?
    NHSN is currently being enhanced to include a feature that allows hospitals to update a CCN or name within NHSN. The new feature is anticipated to be included in NHSN by the end of March 2011.

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Training

  1. Do hospitals that are already using the central line-associated bloodstream infection (CLABSI) protocol need to complete the training again?
    CDC encourages hospitals that are already using the CLABSI protocol to review the training, but it is not a requirement. Hospitals will need to complete an updated consent form when it becomes available in mid-December 2010 and include signatures from the hospital’s executive leadership and primary contact(s) NHSN.
  2. How long does it take to complete the training modules?
    It is estimated that the four required CLABSI training modules will take a total of approximately four hours to complete all modules. Additional information is available on the CDC website.
  3. Is the CLABSI protocol training module current, and is it the one that is going to be in place going forward?
    Yes.

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Digital Certificates

  1. Will NHSN continue to require digital certificates?
    Digital certificates will continue to be used. The CDC anticipates migration to what is called “SAMS,” a new user authentication method, sometime at the end of the first quarter 2011. Additional information regarding this migration will be available prior to its start date.
  2. Are hospital users that have digital certificates required to get another one for CLABSI reporting?
    No, hospital users that have NHSN digital certificates will not receive new digital certificates. However, if an existing NHSN user has a digital certificate due for the annual renewal, the user needs to follow the annual renewal process.
  3. Can a hospital with multiple users use the same digital certificate?
    No, each NHSN user must have his or her own digital certificate. That digital certificate can be loaded onto any number of computers. Each individual must have his or her own digital certificate and cannot share a digital certificate among users. 

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Monthly Data Submission

  1. Please clarify the data submission timeframes in the CMS IPPS Rule.
    The CLABSI data for January, February and March 2011(first quarter 2011) must be submitted to and accepted by NHSN by August 15, 2011. Do not wait until the last minute to submit data. It is strongly encouraged that data is submitted monthly. This allows a hospital the opportunity to analyze the data to ensure that infections are tracked effectively and proactive action can be taken to prevent infections.
  2. Does a hospital have to submit these data to both CMS and NHSN?
    No, CDC will share the data with CMS.

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CMS requirements click here for more information

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