Download the NHSN Guidance: Join the Group, Review/Accept Data Rights Template, and Download Reports
Leapfrog obtains healthcare-associated infection (HAI) data for Section 7B of the Leapfrog Hospital Survey directly from the CDC’s National Healthcare Safety Network (NHSN). Hospitals are required to join Leapfrog’s NHSN Group, enter a valid NHSN ID in the Profile of the Leapfrog Hospital Survey, and submit the 2024 Leapfrog Hospital Survey in order to have their data scored and publicly reported.
The following measures from Section 7: Healthcare-Associated Infections are scored and publicly reported:
- CLABSI: Central line-associated blood stream infections in ICUs and select wards
- CAUTI: Catheter-associated urinary tract infections in ICUs and select wards
- MRSA: Facility-wide inpatient Methicillin-resistant Staphylococcus Aureus Blood Laboratory-identified Events
- CDI: Facility-wide inpatient Clostridium difficile Laboratory-identified Events
- SSI Colon: Surgical Site Infections from Colon Surgery
In addition to downloading HAIs from NHSN, Leapfrog will also obtain teaching status from the NHSN Patient Safety Component (PSC) - Annual Hospital Survey.
HAI data will be available on the Hospital Details Page on July 12 and publicly reported on July 25 for hospitals that:
- Join Leapfrog's NHSN Group and review/accept Leapfrog's Data Rights Template by June 20, 2024*
- Enter a valid NHSN ID in the Hospital Profile of their 2024 Leapfrog Hospital Survey, and
- Submit the 2024 Leapfrog Hospital Survey by June 30.
After July 25, refreshed Survey Results will be available on the Hospital Details Page and the public reporting website on the fifth business day of each month.
Hospitals that have completed the three steps above are also required to download and save their analysis reports from NHSN on the same day as Leapfrog to verify the data downloaded, scored, and publicly reported by Leapfrog. More information may be found in the “NHSN Guidance: Join the Group, Review/Accept Data Rights Template, and Download Reports” PDF linked above.
* Hospitals are not required to “re-join” Leapfrog’s NHSN Group if they joined and conferred rights in previous Leapfrog Hospital Survey Cycles. However, all hospitals in Leapfrog’s NHSN Group must review their Rights Acceptance Report at least annually to ensure that Leapfrog has access to the data from all the locations that were active during the reporting period, even if those locations are no longer active, to ensure that Leapfrog obtains the appropriate SIR for each infection measure. Hospitals must review their Rights Acceptance Report by the first NHSN join-by date of each Survey Cycle and whenever they make changes to their location mapping in NHSN. More information may be found in the “NHSN Guidance: Join the Group, Review/Accept Data Rights Template, and Download Reports” PDF (above).
Deadlines and Reporting Periods
| Join by | Leapfrog will download data from NHSN for all current group members on | Data downloaded from NHSN will be scored and publicly reported for hospitals that submitted the Survey by | HAI Reporting Period | Available on Hospital Details Page and Public Reporting Website on |
|---|---|---|---|---|
| June 25, 2024* | June 26, 2024* | June 30, 2024 |
01/01/2023 - 12/31/2023 |
July 12, 2024 Details Page July 25, 2024 Public Reporting Website |
| August 22, 2024 |
August 23, 2024 |
August 31, 2024 |
01/01/2023 - 12/31/2023 |
September 9, 2024 |
| October 23, 2024 | October 24, 2024 | October 31, 2024 |
07/01/2023 - 06/30/2024 |
November 7, 2024 |
| December 18, 2024** | December 19, 2024** | November 30, 2024 |
07/01/2023 - 06/30/2024 |
January 8, 2025 |
*NHSN notified users of a temporary technical issue that impacted generated Data Analysis Sets in the Patient Safety Component between June 18 and June 21. As a result, Leapfrog rescheduled its download of the Healthcare-Associated Infection (HAI) data for CLABSI, CAUTI, MRSA, CDI, and SSI: Colon to June 26 for hospitals that joined the group by June 25.
**The Leapfrog Hospital Survey closes on November 30, 2024. The last NHSN data download is on December 19, 2024, to incorporate any facilities and corrections from facilities that joined by the last join date of December 18, 2024.
Instructions for Joining Leapfrog's NHSN Group
Please download a copy of the NHSN Guidance: Join the Group, Review/Accept Data Rights Template, and Download Reports (refer to pages 5-10).
Multi-Campus Reporting
In alignment with other sections of the Survey, Leapfrog requires that hospitals within a system report individually to the Leapfrog Hospital Survey. This policy also applies to hospitals that share a Medicare Provider Number, taxpayer ID, hospital license, etc. that are not within a contiguous geographic location. This policy also requires that hospitals report separately to NHSN. NHSN’s policy aligns with Leapfrog's and is stated as follows: “If free-standing facilities are located in physically separate buildings, whether on the same property or over multiple campuses, each individual facility should be enrolled separately in NHSN. This applies even if physically separate facilities share a single CMS Certification Number (CCN).”1
If your facility or system is currently incorrectly enrolled and reporting data from multiple facilities with a single NHSN ID then you will need to follow the steps outlined on page 10 of "NHSN Guidance: Join the Group, Review/Accept Data Rights Template, and Download Reports" PDF (above).
1Policy and instructions taken from the March 2015 NHSN Newsletter, Volume 10, Issue 1. https://www.cdc.gov/nhsn/pdfs/newsletters/nhsn-nl-march_2015.pdf
FAQs Regarding Joining Leapfrog's NHSN Group
Q: What data is being requested?
A: The data being requested by Leapfrog is used to generate standardized infection ratios (SIRs) for CLABSI in ICUs and select wards, CAUTI in ICUs and select wards, facility-wide inpatient MRSA Blood Laboratory-identified Events, facility-wide inpatient C.Diff. Laboratory-identified Events, and SSI: Colon within NHSN.
Q: How will the data be used?
A: Leapfrog will use the data to score your hospital and provide results for Section 7B: Healthcare-Associated Infections (HAIs) in the 2024 Leapfrog Hospital Survey. Results are publicly reported on Leapfrog's Ratings Website at ratings.leapfroggroup.org. Results from Section 7B are also used to calculate Leapfrog Hospital Safety Grades and Leapfrog Value-Based Purchasing (VBP) scores for eligible hospitals.
Q: Will Leapfrog be collecting patient identifiers?
A: No, Leapfrog will not be collecting any patient identifiers. When reviewing the Data Rights Template, hospitals will see that we are requesting patient data “without identifiers.”
Q: Will the data be shared with other members of the NHSN Group?
A: No, a facility that joins a group does not have access to any data from other facilities in the group. Data will only be shared with The Leapfrog Group.
Q: Will joining the Leapfrog NHSN Group prohibit us from joining other NHSN Groups?
A: No, facilities may join multiple groups within NHSN.
Q: Who from our hospital needs to complete the "join group" process in NHSN?
A: An administrative-level NHSN user is needed to join a Group within NHSN and complete the "Confer Rights" process.
Q: After joining the NHSN Group, what else is required?
A: When a hospital first joins the group, they are asked to “confer rights” to The Leapfrog Group. The confer rights process specifies which NHSN data will be shared with Leapfrog; the Data Rights Template is the document that outlines this information. Leapfrog requires that all hospitals in Leapfrog's NHSN Group review their Data Rights Template annually, before the June 20, 2024, NHSN join‑by-date.
In addition to joining Leapfrog’s NHSN Group and conferring rights, hospitals must provide a valid NHSN ID in the Hospital Profile and submit the 2024 Leapfrog Hospital Survey in order to be scored and publicly reported on the five infection measures. Once a hospital joins the NHSN Group, accepts (or re-reviews) the Data Rights Template, and submits the 2024 Leapfrog Hospital Survey, there is nothing else that is required for that Survey Cycle.
Hospitals will be able to view the NHSN data that is being pulled into their Leapfrog Hospital Survey results by accessing their Hospital Details Page on the dates listed in the "Deadlines and Reporting Periods" table featured above.
Q: Will Leapfrog notify hospital if the Data Rights Template is updated and they need to re-accept in in NHSN?
A: Yes, Leapfrog will e-mail the NHSN administrator of each facility that is a member of our NHSN group if we update the data we are requesting access to. Hospitals will be prompted to review the updated Data Rights Template and re-accept it when they next log into NHSN. Failure to do so will result in leaving Leapfrog’s NHSN Group and Leapfrog will no longer be able to obtain NHSN data for your facility on these five infection measures. You will be reported as “Declined to Respond” for all five infection measures in Section 7B: Healthcare-Associated Infections.
Q: How often is Leapfrog updating the HAI data? Won't regular updating cause changes to the data?
A: Leapfrog will obtain data from NHSN four times per Survey Cycle. This allows Leapfrog to obtain data for new hospitals that may not join the NHSN Group by the first deadline and to use the most current data. The reporting period for the infection measures is updated twice. The reporting period of 01/01/2023 - 12/31/2023 is used for the June and August Downloads. The reporting period of 07/01/2023 - 06/30/2024 is used for the October and December downloads. Within a reporting period, a hospital’s data would only change if they update the surveillance or survey data submitted for that reporting period within NHSN.
Q: How will older data be handled for facilities that need to go through the process of separating their multi-campus hospitals and obtaining new OrgIDs within NHSN? For example, if a pediatric hospital has been reporting with their adult hospital and now needs to be set up with its own OrgID in NHSN, will the hospital need to back-fill the data from 2023 or will there not be any data available for that time period?
A: Hospitals should follow the instructions provided above for multi-campus reporting (also in NHSN’s March 2015 newsletter) to enroll their new facilities in NHSN and start reporting separately at the start of a new quarter. There should be no need to fill in any historical data and doing so would create problems with risk-adjustment and in verifying CMS data. Hospitals with new OrgIDs will likely not have enough data and will be reported as “Unable to Calculate Score” for the 2024 Leapfrog Hospital Survey. It’s important that hospitals start the process of separating their campuses out at the start of a new quarter and as soon as possible.
Q: What units/locations are included in each of the HAI CMS IPPS reports downloaded by Leapfrog?
A: Information on the units included in IPPS reports sent to CMS by NHSN on behalf of hospitals (also utilized by Leapfrog) may be reviewed here (see ‘Healthcare Facility HAI Reporting Requirements to CMS via NHSN Current and Proposed Requirements January 2019’): https://www.cdc.gov/nhsn/cms/index.html. When hospitals join Leapfrog’s NHSN Group, the Data Rights Template will default to all applicable units/locations.
Q: Why might there be discrepancies between what a hospital downloads from NHSN for the CMS IPPS reports and what is shown on CMS Hospital Compare for the same reporting period?
A: There can be differences for a variety of reasons:
- The hospital shares a CMS Certification Number (CCN) and their data is aggregated before it is sent to CMS and displayed on Hospital Compare.
- Hospital Compare data is frozen based on the quarterly reporting deadline, whereas NHSN is constantly changing if a hospital changes its data. NHSN encourages hospitals to save their CMS IPPS reports from NHSN at the end of each reporting period.
Q: Who should hospitals contact if they have other questions?
A: Please contact Leapfrog's Survey Help Desk. Some questions may need to be re-directed to NHSN: https://www.cdc.gov/nhsn/about-nhsn/helpdesk.html.