NHSN Data Validation

healthcare worker holding a stethoscope Internal Validation: Active efforts by a reporting facility to assure completeness and accuracy of NHSN data.

External Validation: Survey and audit process by external agency to assure quality of NHSN surveillance and reporting.

NHSN Validation Guidance and Resources for 2017

For Reporting Facilities: 2017 Internal Validation Guidance and Toolkit collapsed

For Auditors: 2017 External Validation Guidance and Toolkit collapsed

2017 Resources collapsed

NHSN Validation Guidance and Resources for 2016

For Reporting Facilities: 2016 Internal Validation Guidance and Toolkit collapsed

For Auditors: 2016 External Validation Guidance and Toolkit collapsed

2016 Resources collapsed

NHSN Validation Guidance and Resources for 2015

For Reporting Facilities: 2015 Internal Validation Guidance and Toolkit collapsed

For Auditors: 2015 External Validation Guidance and Toolkit collapsed

2015 Resources collapsed

NHSN Validation Guidance and Resources for 2014

For Reporting Facilities: 2014 Internal Validation Guidance and Toolkit collapsed

For Auditors: 2014 External Validation Guidance and Toolkit collapsed

2014 Resources collapsed

NHSN Validation Guidance and Resources for 2013

For Reporting Facilities: 2013 Internal Validation Guidance and Toolkit collapsed

For Auditors: 2013 External Validation Guidance and Toolkit collapsed

The National Healthcare Safety Network (NHSN) is utilized by 32 states, the District of Columbia and the Centers for Medicare and Medicaid Services (CMS) for mandatory, public reporting of healthcare-associated infections (HAIs). Validation activities have been conducted in many states to document compliance with NHSN protocols, evaluate consistency in applying case definitions, assess the adequacy of case detection, and determine the accuracy and completeness of data reported by facilities and to the public. This toolkit aims to provide a standard approach to HAI data validation to assure nationwide data quality and to enhance fairness under current and planned reimbursement programs that use NHSN data. However, a “one-size-fits all” approach to validation is not often feasible due to differences in state mandates, access to data, and resources. Given these differences, the toolkit has been designed to offer a suggested method, with room for variation, and tools that can be implemented per state-specific goals and resources. The goal is to assist in developing and implementing audit and validation programs that enhance the accuracy and completeness of data reported to NHSN.

2013 External Validation Guidance and Toolkit[PDF – 7M]
Tool Kit Highlights:
- Guidance for Conducting Validation – Broad overview of how to select HAIs and facilities to validate, as well as details for on-site versus off-site validation activities.
- Templates for Facility Laboratory Line Lists – Suggested templates of variables to request from facilities participating in validation for each of the six HAIs.
- Surveys to Evaluate Facility Surveillance Activities – Survey tools to evaluate surveillance activities such as training, denominator counting, and HAI-specific surveillance methods at the facility level.
- Selection of Facilities for External Audit of Medical Records – Detailed instructions on how to rank and sample facilities to validate.
- Selection of Medical Records for Review – Detailed HAI-specific instructions on how to sample medical records for facility validation.
- Medical Record Abstraction Tools (MRATs) – Tools that include HAI-specific algorithms and logic designed to establish presence or absence of required criteria for NHSN case definitions and to provide support to avoid common errors.