FAQs: Annual Surveys

Annual Hospital Survey: Teaching Status

Q1: Which designation of teaching status should I indicate on the annual hospital survey?

The NHSN teaching status categories are as follows:

  • Major: Facility trains medical students and/or nursing students, and post-graduate residents. Note that there is no minimum number of students that must be present in your facility to meet this designation, and it is not necessary for your facility to be attached/affiliated with a medical school.
  • Graduate: Facility trains only post-graduate medical (MD/DO only) residents/fellows
  • Undergraduate: Facility trains current (undergraduate) medical students and/or nursing students

Select the highest level that your facility meets.


Annual Hospital Survey: units designated as Inpatient Rehabilitation Facilities (IRFs)

Q2: My acute care hospital includes a CMS-certified Rehab Unit mapped as a location within the hospital (i.e., the CCN for the Rehab unit includes an ‘R’ or ‘T’ in the 3rd position). Do I include the number of rehab beds from this unit on the annual hospital survey, the annual rehab survey, or both?

The number of rehab beds should be counted on both the hospital and rehab surveys. On the hospital survey, include these beds in the count for “All other inpatient locations”. In addition, counts from these locations should be included in the total facility patient days and admissions on the hospital survey.

 

Q3: The Rehab unit/facility is physically separated from my acute care hospital and is enrolled as a separate facility in NHSN. Do I include the number of rehab beds from this unit on the annual hospital survey?

Since the Rehab unit/facility is a separate NHSN facility, the number of rehab beds, patient days, and admissions should NOT be counted on the hospital survey, and will be included only on the rehab survey.

 

Q4: I have a free-standing IRF that is enrolled as a separate facility in NHSN (i.e., last 4 digits of the IRF CCN are between 3025-3099). Do I include the number of rehab beds from this unit on the annual hospital survey?

The number of beds, patient days, and admissions from the free-standing IRF should only be counted on the Rehab survey.


Annual Hospital Survey:  units designated as Inpatient Psychiatric Facilities (IPFs) and Skilled Nursing Facilities (SNFs)

Q5: My hospital has an IPF and/or SNF unit located within the hospital. Do I include counts from these units on the annual hospital survey for patient days, admissions, and total bed size?

IPF: Yes, counts from the IPF unit should be included on the annual hospital survey. If your IPF unit is not geographically located within the hospital, contact the NHSN helpdesk for more guidance.

SNF: If your SNF has a separate CCN from the hospital, it should be enrolled as a separate NHSN facility. In this case, counts from the SNF unit should NOT be counted on the acute care hospital’s survey.  If your SNF shares a common CCN with the acute care hospital, then these counts should be included on the hospital survey.


Annual Survey bed size for all facility types

Q6: During the previous calendar year my facility’s number of beds changed during the year. What number should I report for the total number of beds on the annual survey?

Users should report the number of beds that were used for the majority (six months or greater) of the previous calendar year in a facility.


Annual Surveys for newly enrolled facilities

Q7: My facility just opened last month and we are currently enrolling in NHSN. Do I need to complete an annual survey?

All facilities that have recently joined NHSN do have to complete a survey upon enrollment. However, if your facility was not operational during the prior calendar year, you will indicate this during your enrollment process. Then, you will be prompted to complete only select questions from the annual survey. The questions that are unable to be answered at the time of enrollment will be grayed out. At the start of the calendar year following when a facility has enrolled in NHSN, they will have to complete the same annual survey, but will have to complete all the questions. For example, if you enroll in NHSN during 2018 but were not operational in 2017, you will complete a shortened version of the 2017 PSC annual survey containing basic demographic questions. The next year, 2018, you will have to complete the entire 2017 PSC annual survey with information from 2017.


Annual surveys for HCP Influenza Vaccination Summary Module

Q8: Which surveys are required to be completed for the HCP Influenza Vaccination Summary Module?

At this time, no annual surveys are required to participate in this module. However, NHSN encourages users to complete the (optional) “Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel”. The data collected in this brief survey, including methods a facility uses to deliver influenza vaccine to its HCP, are very helpful to CDC personnel.  If you elect to complete this survey, only one survey should be completed during the influenza season. More information on the survey can be found here: Surveillance for Healthcare Personnel Vaccination.


Annual surveys for all enrolled facilities

Q9: When are the patient safety component annual surveys due?

Patient Safety annual facility surveys must be completed and saved to your NHSN account no later than March 1st of each calendar year. Failure to save a survey to NHSN by this date will result in future monthly reporting plans to be locked for editing until the most recent survey is completed.

 

Q10: For total number of beds set-up and staffed, does my facility count only the number of staffed beds, or do we count the total number of beds we have available in case we need to add overflow beds?

Enter the maximum number of beds used at any time during the calendar year for total number of beds used.

 

Q11: I need to make a correction to my saved survey. Am I allowed to edit survey data after I’ve already submitted it?

All PSC Annual Surveys can be edited at any time in NHSN. Please remember survey data is used for risk adjustment calculations that are used in generating SIRs. Changes to these values may change your SIR. Data that has been submitted to CMS Inpatient Quality Reporting will not be re-submitted after a deadline has passed even if edited survey data changes your facility’s SIR.


Annual Hospital Survey: Neonatal Admissions

Q12: Who in my facility should I to contact that collects admission data by birthweight?

To collect admissions data by birthweight category, we suggest first speaking to the NICU Medical Director or Nursing Director, as they are usually familiar with such data and how to access it. In the event that neither can assist, try asking Quality Data Analysts in either the NICU or the hospital. They often are able to access admissions data by birthweight. These analysts may have different names in different hospitals and are usually part of a larger department available to assist with data needs.

 

Q13: My hospital provides care to well newborns, but we do not have a special care nursery or NICU. Are we required to complete the neonatal portion of the survey?

Hospitals providing any level of neonatal care are required to complete neonatal-specific survey questions. Hospitals that provide care to well newborns, but do not have a Level II or higher neonatal unit will record 0 admissions for questions 26 and 27 on the 2018 Hospital Survey.

 

Q14: As part of our NHSN CLABSI reporting plan, we collect information on patient days by birthweight category, but we do not collect information on the number of admissions by birthweight category. Can you clarify that questions 26 and 27 are asking about admissions and not patient days?

Questions 26 and 27 areasking hospitals to report the number of annual admissions. Additional data collection may be required to determine the number of annual admissions by birthweight category, but only report admissions and not patient days

 

Q15: How are out born admissions defined?

Out born admission: admission of an infant delivered outside of your hospital

 Inborn admission: admission of an infant delivered inside of your hospital

 

Q16: Is question 27 asking about the weight of the infant at birth or their weight upon admission?

Question 27 is asking about the weight of the infant at birth.