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

2017 Internal Validation Guidance and Toolkit [PDF – 1 MB]

For Auditors: 2017 External Validation Guidance and Toolkit

2017 External Validation Guidance and Toolkit [PDF – 6 MB]

2017 Resources

2017 NHSN Patient Safety Component Manual [PDF – 6 MB]
Surveillance Training Material
- CLABSI
- CAUTI
- CLIP
- VAE
- SSI
- Prevention Process and Active Surveillance Testing Outcome Measures
- Evaluating Entered Data for Completeness, Consistency and Accuracy
- Introduction to NHSN Analysis
- Advanced NHSN Analysis
MDRO & CDI LabID Event Calculator Ver 2.0 (must have JavaScript enabled)
Ventilator-Associated Event Calculator (Version 4.0) (must have JavaScript enabled)
2017 Operative Procedure Code Documents
The documents listed below should be used for procedures performed in 2017.
- ICD-10-PCS Procedure Code Mapping to NHSN Operative Procedure Codes [XLSX – 611K]
- Current Procedural Terminology (CPT) Procedure Code Mapping to NHSN Operative Procedure Codes [XLSX – 313K]
- Additional Guidance for use with NHSN Operative Procedure Codes
  - ICD-10-PCS & CPT Codes – Guidance for HPRO & KPRO Procedure Details [XLSX – 46K]
    This guidance document may be used for completing the NHSN procedure details for HPRO – hip arthroplasty and/or KPRO – Knee arthroplasty operative procedures.
  - FUSN ICD-10-PCS Codes – Guidance for Spinal Level and Approach. [XLSX – 30K]
    This supplemental guidance may be used to complete the spinal level and approach fields in the Operative Procedure Details section for FUSN procedures.
  - ICD-10 CM Diabetes Diagnostic Codes [XLSX – 15K]ICD-10-CM codes included in this spreadsheet are acceptable for use to answer “YES” to “Diabetes Mellitus” for completing the NHSN Operative Procedure Details.
  - ICD-10-CM/PCS Codes for ‘prior infection at hip or knee joint’ denominator form question [XLSX – 20K]Use ICD-10-PCS/CM diagnosis or procedure codes included in this spreadsheet to determine if patient meets criteria for ‘prior infection at index joint’.
- Document detailing changes made to the 2016 operative procedure codes
  - Summary of 2016 Code Changes [XLSX – 343K]
    This document identifies changes made to the codes 2016 operative procedure codes. It should not be used for identifying NHSN operative procedures or SSI events.

NHSN Validation Guidance and Resources for 2016

For Reporting Facilities: 2016 Internal Validation Guidance and Toolkit

2016 Internal Validation Guidance and Toolkit [PDF – 1M]

For Auditors: 2016 External Validation Guidance and Toolkit

2016 External Validation Guidance and Toolkit [PDF – 3M]

2016 Resources

2016 NHSN Patient Safety Component Manual [PDF – 4M]
Surveillance Training Material
- CLABSI
- CAUTI
- CLIP
- VAE
- SSI
- Prevention Process and Active Surveillance Testing Outcome Measures
- Evaluating Entered Data for Completeness, Consistency and Accuracy
- Introduction to NHSN Analysis
- Advanced NHSN Analysis
MDRO & CDI LabID Event Calculator Ver 2.0 (must have JavaScript enabled)
Ventilator-Associated Event Calculator (Version 4.0) (must have JavaScript enabled)
2016 Procedure Code Documents
The documents listed below should be used for procedures performed in 2016.
- ICD-10-PCS Procedure Code Mapping to NHSN Operative Procedure Codes for Procedures Occurring On or After October 1, 2015 [XLSX – 475K]
- Current Procedural Terminology (CPT) Procedure Code Mapping to NHSN Operative Procedure Codes for Procedures Occurring On or After October 1, 2015 [XLSX – 337K]
- Additional Guidance for use with NHSN Operative Procedure Codes
  - Guidance for HPRO and KPRO Procedure Details [XLSX – 41K]
    This guidance document may be used for completing the NHSN procedure details for HPRO – hip arthroplasty and/or KPRO – Knee arthroplasty operative procedures.
  - FUSN ICD-10-PCS Codes – Guidance for Spinal Level and Approach [XLSX – 31K]
    This supplemental guidance may be used to complete the spinal level and approach fields in the Operative Procedure Details section for FUSN procedures.
  - ICD-10 CM Diabetes Diagnostic Codes [XLSX – 16K]
    ICD-10-CM codes included in this spreadsheet are acceptable for use to answer “YES” to “Diabetes Mellitus” for completing the NHSN Operative Procedure Details.
  - ICD-10-CM/PCS Codes for ‘prior infection at hip or knee joint’ denominator form question [XLSX – 20K]
    ICD-10-CM codes included in this spreadsheet are acceptable for use to answer “YES” to “Diabetes Mellitus” for completing the NHSN Operative Procedure Details.
  - Summary of 2016 Code Changes [XLSX – 343K]
    This document identifies changes made to the codes 2016 operative procedure codes. It should not be used for identifying NHSN operative procedures or SSI events.

NHSN Validation Guidance and Resources for 2015

For Reporting Facilities: 2015 Internal Validation Guidance and Toolkit

2015 Internal Validation Guidance and Toolkit [PDF – 896K]

For Auditors: 2015 External Validation Guidance and Toolkit

2015 External Validation Guidance and Toolkit [PDF – 2M]

2015 Resources

NHSN Patient Safety Manual 2015 [PDF – 4M]
Surveillance Training Material
- CLABSI
- CAUTI
- CLIP
- VAE
- SSI
- Prevention Process and Active Surveillance Testing Outcome Measures
- Evaluating Entered Data for Completeness, Consistency and Accuracy
- Introduction to NHSN Analysis
- Advanced NHSN Analysis
MDRO & CDI LabID Event Calculator Ver 2.0 (must have JavaScript enabled)
Ventilator-Associated Event Calculator (Version 4.0) (must have JavaScript enabled)
ICD9-CM Procedure Code Mapping to NHSN Operative Procedure Categories January 2013. [XLSX – 174K]
Mapping of ICD-9-CM Procedure Codes to NHSN Operative Procedure categories.
ICD-9 Mapping Tool for HPRO and KPRO February 2014 [PDF – 192K]
This is an update to the Mapping Tool guidance that was sent out last week for those NHSN users who are following HPRO – hip Arthroplasty and KPRO – Knee Arthroplasty in their monthly surveillance plan. We realized there is a defect in the NHSN system that will cause an error message with the mapping tool we provided. This update addresses how to work around this issue.

NHSN Validation Guidance and Resources for 2014

For Reporting Facilities: 2014 Internal Validation Guidance and Toolkit

2014 Internal Validation Guidance and Toolkit [PDF – 1M]

For Auditors: 2014 External Validation Guidance and Toolkit

2014 External Validation Guidance and Toolkit [PDF – 2M]

2014 Resources

NHSN Patient Safety Manual 2014 [PDF – 7M]
Surveillance Training Material
- CLABSI
- CAUTI
- CLIP
- VAE
- SSI
- Prevention Process and Active Surveillance Testing Outcome Measures
- Evaluating Entered Data for Completeness, Consistency and Accuracy
- Introduction to NHSN Analysis
- Advanced NHSN Analysis
Tennessee Checklists
MDRO & CDI LabID Event Calculator
Ventilator-Associated Event (VAE) Calculator v2.1 (must have JavaScript enabled)

NHSN Validation Guidance and Resources for 2013

For Reporting Facilities: 2013 Internal Validation Guidance and Toolkit

2013 Internal Validation Guidance and Toolkit [PDF – 800 KB]

For Auditors: 2013 External Validation Guidance and Toolkit

2013 External Validation guide 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.