Change Summary Issued June 28, 2021 -
- Section 7B Healthcare-Associated Infections: Updated the 12-month reporting period used for obtaining the healthcare-associated infection data from the Center for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) to use three quarters of data from 2019 and one quarter of data from 2020 for Leapfrog’s July and August NHSN data pulls: 04/01/2019 – 12/31/2019 AND 07/01/2020 – 09/30/2020. Leapfrog will announce the reporting period for the October and December NHSN data pulls following the publication of the CMS FY 2022 Hospital Inpatient PPS final rule. Find a list of all NHSN data pulls and reporting periods below.
Hospitals are required to join Leapfrog’s NHSN Group in order to be scored and publicly reported on the following measures from Section 7 Managing Serious Errors:
- Central line-associated blood stream infections (CLABSI) in ICUs and select wards
- Catheter-associated urinary tract infections (CAUTI) in ICUs and select wards
- Facility-wide inpatient Methicillin-resistant Staphylococcus Aureus (MRSA) Blood Laboratory-identified Events
- Facility-wide inpatient Clostridium difficile (C. Diff.) Laboratory-identified Events
- Surgical Site Infections from Colon Surgery (SSI: Colon)
In addition, Leapfrog will obtain teaching status from the NHSN Patient Safety Component - Annual Hospital Survey.
Data will be available on the Hospital Details Page, as well as scored and publicly reported by Leapfrog, starting in August for hospitals that:
- Join Leapfrog's NHSN Group and review/accept Leapfrog's Data Rights Template before July 21*
- Enter a valid NHSN ID in the Profile Section of their 2021 Leapfrog Hospital Survey, and
- Complete, affirm, and submit Section 7 of the 2021 Leapfrog Hospital Survey by July 31.
*Hospitals are not required to “re-join” Leapfrog’s NHSN Group if they joined and conferred rights for the 2017, 2018, 2019, or 2020 Leapfrog Hospital Survey. 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access to the data from all of the locations that were active during the reporting period, even if those locations are no longer active, to ensure that Leapfrog obtains the appropriate SIR. Hospitals must review their Rights Acceptance Report before the July 21, 2021 NHSN join-by date and whenever updates are made to their location mapping in NHSN. More information may be found in the “NHSN Guidance: Join the Group, Data Rights Template, and Downloading 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 have submitted Section 7 by||HAI Reporting Period||Available on Hospital Details Page and Public Reporting Website on|
|July 21, 2021||July 22, 2021 (grouped by quarter)||July 31, 2021||
04/01/2019 - 12/31/2019
07/01/2020 - 09/30/2020
|August 6, 2021|
|August 23, 2021||August 24, 2021 (grouped by quarter)||August 31, 2021||
04/01/2019 - 12/31/2019
07/01/2020 - 09/30/2020
|September 8, 2021|
|October 21, 2021||October 22, 2021||October 31, 2021||TBD||November 5, 2021|
|November 30, 2021||December 21, 2021**||November 30, 2021||TBD||January 7, 202|
** The Leapfrog Hospital Survey closes on November 30, 2021. The last NHSN data pull is on December 21, 2021 to incorporate any corrections facilities that joined by the last join date of November 30, 2021 may have made to their NHSN data since the last NHSN data pull.
Leapfrog will download data four times per Survey cycle (April 1 – November 30), according to the dates and reporting periods listed in the table above, for all current members of our NHSN group that have provided an accurate NHSN ID in the Profile of their 2021 Leapfrog Hospital Survey and have submitted Section 7: Managing Serious Errors.
Hospitals that fail to join Leapfrog’s NHSN Group and/or provide a valid NHSN ID in the Profile Section of their 2021 Leapfrog Hospital Survey and/or complete, affirm, and submit Section 7 of their 2021 Leapfrog Hospital Survey will be publicly reported as “Declined to Respond” for all five infection measures.
Leapfrog recommends that hospitals follow the instructions provided in the NHSN Guidance: Join the Group, Data Rights Template, and Downloading Reports document and save copies of the NHSN 2020 Patient Safety Component – Annual Hospital Survey and CMS IQR Reports on the same day that Leapfrog will be downloading the data from NHSN for all current group members.
Instructions for Joining Leapfrog's NHSN Group
Please download a copy of the NHSN Guidance: Join the Group, Data Rights Template, and Downloading Reports (refer to pages 4-7).
Note: Both adult and pediatric facilities are required to join Leapfrog's NHSN Group in order to have data reported for Section 7B of their Leapfrog Hospital Survey.
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 included on page 8 of NHSN Guidance: Join the Group, Data Rights Template, and Downloading Reports.
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: Will the data be shared with other members of the 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 Leapfrog.
Q: How will the data be used?
A: The data will be used to score your facility and provide results for Section 7B Healthcare-Associated Infections in the 2021 Leapfrog Hospital Survey.
Q: What data is being requested?
A: The data being requested by Leapfrog is used to generate standardized infection ratios 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.
Immediately after joining the Group, the facility will be taken to a screen listing the data that the Group is requesting access to, referred to as the "Data Rights Template." A or in the template indicates that a particular piece of data is being requested by the Group. The Data Rights Template will automatically include both inactive and active locations that a facility has mapped. Please leave the template with all locations checked for each applicable HAI type, and only mark items on the template as “N/A” or unselect locations if they do not apply to your facility. Hospitals must include any locations that were active during the reporting period even if they are currently inactive to ensure that Leapfrog obtains the appropriate SIR. The facility must select the "Accept" button at the bottom of the screen in order to accept the template of data rights and share data with Leapfrog.
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: Who from our facility needs to complete the "join group" process within 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, which specifies the data that would be shared with Leapfrog. Leapfrog has set up a Data Rights Template, which specifies the data we are requesting. Leapfrog requires that all Hospitals in Leapfrog's NHSN Group review their Rights Acceptance Report annually, before the July 21, 2021 NHSN join-by-date. In addition to joining Leapfrog’s NHSN Group, hospitals must provide a valid NHSN ID in the Profile Section, and complete, affirm, and submit Section 7 of the 2021 Leapfrog Hospital Survey in order to be scored and publicly reported on the infection measures. Once a facility joins and accepts the data sharing and has submitted the necessary items in their Survey, there is nothing else that is required. If Leapfrog updates the data rights we are requesting, then the NHSN administrator would be notified when they next log into NHSN. They have the option to accept the updated data sharing request or leave the group. Hospitals will be able to view the 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 hospitals if the Data Rights Template is updated and they need to re-accept it within 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 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 will change after the first two data pulls. The first two pulls will use the reporting period of 04/01/2019 - 12/31/2019 AND 07/01/2020 - 09/30/2020. The reporting period for the second two data pulls is yet to be determined. 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. This should be rare as there is at least a 6-month reporting lag.
Q: When will the Hospital Details Page be published and how often will it be refreshed?
A: Data will be available on the Hospital Details Page, as well as scored and publicly reported by Leapfrog, starting in August for hospitals that:
- Join Leapfrog's NHSN Group and review/accept Leapfrog's Data Rights Template by July 21,
- Have a valid NHSN ID provided in the Profile Section of their 2021 Leapfrog Hospital Survey,
- Have completed, affirmed, and submitted Section 7 of the 2021 Leapfrog Hospital Survey by July 31.
For all deadlines and release dates, please see the “Deadlines and Reporting Periods” table featured above.
Hospitals are not required to “re-join” Leapfrog’s NHSN Group if they joined and conferred rights for the 2017, 2018, 2019, or 2020 Leapfrog Hospital Survey. 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 of 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. Hospitals must review their Rights Acceptance Report before the July 21, 2021 NHSN join-by date and whenever updates are made to their location mapping in NHSN. More information may be found in the NHSN Guidance: Join the Group, Data Rights Template, and Downloading Reports PDF.
Q: Will joining the Leapfrog NHSN Group prohibit us from joining other NHSN Groups?
A: No, facilities may join multiple groups within NHSN.
Q: How will older data be handled for facilities that need to go through the process of separating out their multi-campus hospitals and getting new OrgIDs within NHSN?
For instance, if a pediatric facility has been reporting with their adult hospital and now needs to be set up with its own OrgID in NHSN, will the facility need to back-fill in the data from 2020 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 2021 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: Why might there be discrepancies between what a hospital downloads from NHSN for the CMS IQR reports and what is shown on CMS Hospital Compare for the same reporting period?
A: There can be differences for a variety of reasons:
- Hospital shares a Medicare Provider Number 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 their data. NHSN encourages hospitals to save their CMS IQR reports from NHSN at the end of each reporting period.
Q: Who should hospitals contact if they have other questions?
Q. What units/locations are included in each of the HAI CMS IQR reports downloaded by Leapfrog?
A: Information on the units included in IQR 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. Hospitals should only make updates to the Data Rights Template when units are not applicable to their facility.