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NHSN Annual Facility Survey

If your facility is enrolled in the National Healthcare Safety Network (NHSN), then submitting an annual facility survey for the previous year is a requirement. If your facility was not operational in 2023 but you are enrolling, this information must be provided at the time of enrollment.

 

The deadline for completion is March 1st of each calendar year. If your facility has been operational, it is important to update the survey to accurately address various components of the survey based on the previous year. There are a variety of online educational modules available to assist facilities through the completion process. You will also find instructions for completing the survey. You can find this information on the Centers for Disease Control and Prevention (CDC) website


It is best to begin working on the survey well in advance of the deadline for submission.

We recommend reviewing all components of the survey and delegating review and completion to personnel that oversee corresponding departments. Assistance from leadership from the following departments will be needed to complete the survey:

 

  • Infection Prevention
  • Microbiology/Lab
  • Quality
  • Pharmacy
  • Nursing
  • Facilities
  • Medical Records
  • Contractors, if applicable

Facilities will need to provide response to a variety of questions on the following topics:

  • Type of facility
  • Services Provided
  • Volumes
  • Laboratory testing capabilities and equipment
  • Infection Prevention Practices
  • Neonatal/newborn level of care if applicable
  • Antimicrobial Stewardship Practices
  • Sepsis Management and Practices
  • Facilities Water Management


You can preview the various NHSN annual survey questionnaires associated with the corresponding facility types listed below:


 

We recommend that you check with your NHSN administrator to determine if your facility’s annual survey has been completed and submitted. It may also be a good idea to create a task force that includes departmental leaders. This provides a great opportunity to delegate the task of completion of survey questions relative to their respective departments.

HCE Global is Here to Help

HCE Global understands the challenges that healthcare facilities are facing today. We are here to help. Using a customizable approach, we will help you navigate through even the toughest of challenges. We pride ourselves on helping clients achieve and maintain a status of excellence in the healthcare industry.


Be sure to visit Our Website for a full list of services we provide.

Contact us today at +1 (800) 813-7117 to schedule a free consultation

February 10, 2025
It is that time of year again. At least for acute care hospitals, long-term acute care (LTAC) hospitals and inpatient rehabilitation facilities (IRF) who report to The National Healthcare Safety Network (NHSN). If annual surveys are not reported by March 1 st , then your organization will not be permitted to enter monthly reporting plans until the annual survey has been completed. Although there are just a few weeks to go, early planning is the key. It is important to consider that responses to the Annual Survey questions are a collaborative effort. Planning a meeting in advance with key stakeholders will help to ease the stress of completing what some may consider to be a daunting task. Be sure to coordinate with Facilities Managers, Pharmacists, Laboratory, Nursing, Infection Prevention and Quality leaders on annual survey responses. Although individuals who are responsible for report submission may find that some of the data has not changed significantly from the previous year, we have identified that some questions have been removed while additional questions have been added. If you are new to NHSN reporting and have not yet completed an annual survey, you will find an alert reminding you on your dashboard upon logging in. Keep in mind that the survey you are completing requires data from the previous calendar year. You will be submitting data for 2024 due March 1 st , 2025. There are a variety of questions that will require information about metrics, facility type, infection prevention practices, laboratory testing methods, water quality management, and antimicrobial stewardship practices for example. Instructions on completing your organization’s annual survey click on the link below that corresponds with your facility type: Instructions for Completing Annual Hospital Survey Instructions for Completing LTAC Annual Survey Instructions for Completing IRF Annual Survey OSHA requires the following facilities to complete an annual occupational injury and Illness Report: Ambulatory Health Care Servies General Medical and Surgical Hospitals Psychiatric and Substance Abuse Hospitals Specialty Hospitals Skilled Nursing Facilities For a complete list of facilities required to report annually via electronic submission and for additional information on Standard 1904 Subpart E Appendix B click on the following link: OSHA Injury and Illness Reporting Requirements . Much like NHSN annual surveys, this reporting is also for the prior calendar year. Your deadline for submission is March 2, 2025. If your organization has not previously been reporting, please note that you will need to set up an Injury Tracking Application (ITA) account. For complete instructions, click on the following link User Guide . Individuals who are responsible for report completion and submission should have a clear understanding of criteria that constitutes a work-related injury. They will also need to know if the employee missed days of work because of injury or illness. If an employee was restricted from usual work activities or reassigned to a new role as a result of the injury or illness this information must be documented. If an employee required care beyond basic first aid, this will also need to be reported. Reporters should not include Protected Health Information (PHI). For a brief tutorial on OSHA annual reporting requirements, click on the following link OSHA Injury and Illness Reporting . Our experts understand the challenges that all healthcare facilities are facing today. Using a customizable approach, we will help you navigate through even the toughest of challenges. Whether you are in need of mock surveys, leadership training, corrective action plans or ongoing support services, we can help! We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry. Be sure to browse Our Website for a full list of services we provide. Contact us today at +1 (800) 813-7117 to schedule a free consultation. References: https://www.cdc.gov/nhsn/forms/instr/57_103-toi.pd https://www.osha.gov/laws-regs/regulations/standardnumber/1904/1904SubpartEAppB https://www.osha.gov/sites/default/files/ita_user_guide.pdf https://www.osha.gov/sites/default/files/osha_rktutorial.pdf
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In 2002 The Joint Commission (TJC) first established the National Patient Safety Goals (NPSG) Program. In 2003, TJC rolled out the first set of NPSG’s. Each year, TJC prioritizes patient safety goals for various healthcare programs.
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