FAQs: Annual Surveys

Verify that all questions have been answered, then hit the “submit” button.  “Saving” only saves your data so you can come back to add responses. By hitting the “submit” button, it says that you are finished with your answers for the survey.

Major: Facility trains medical students and/or nursing students, and post-graduate medical (MD/DO only) residents/fellows.

Graduate: Facility trains only post-graduate medical (MD/DO only) residents/fellows

Undergraduate: Facility trains current medical students and/or nursing students

Select the highest level that your facility meets.

Note: There is no minimum number of students that must be present in your facility to meet this designation, and it is not necessary for your facility to be attached/affiliated with a medical school.

The number of rehab beds should be counted on both the hospital and CMS-IRF unit surveys. On the hospital survey, include these beds in the count for “All other inpatient locations”. In addition, counts from these locations should be included in the total facility patient days and admissions on the hospital survey.

Since the Rehab facility is a separate NHSN facility, the number of rehab beds, patient days, and admissions should NOT be counted on the hospital survey and will be included only on the REHAB survey.

IPF: Yes, counts from the IPF unit should be included on the annual hospital survey, even if the IPF has a separate CCN. If your IPF facility is not geographically located within the hospital, the counts should NOT be included with hospital’s count. Instead, the IPF facility should enroll as a separate NHSN facility and complete a separate annual facility survey.

SNF: If your SNF has a separate CCN from the hospital, it should be enrolled as a separate NHSN facility. In this case, counts from the SNF unit should NOT be counted on the acute care hospital’s survey.  If your SNF shares a common CCN with the acute care hospital, then these counts should be included on the hospital survey.

Users should report the number of beds that were setup and staffed for the majority (six months or greater) of the previous calendar year in a facility. If the change occurred with an equal number of months captured in a year, then users should report the number of total beds that were in place at the end of the year. Do not use the number of licensed beds.

All facilities that have recently joined NHSN do have to complete a survey upon enrollment for the prior calendar year. However, if your facility was not operational during the prior calendar year, you will indicate this during your enrollment process. Then, you will be prompted to complete only select questions from the current calendar year’s partial Patient Safety annual survey. The questions that are unable to be answered at the time of enrollment will be grayed out. However, at the start of the calendar year following when a facility has enrolled in NHSN, they will have to complete the same annual survey, but at this time, they will have to complete all the questions. 

 If NOT operational in the prior year:  

If your facility was not operational during the prior calendar year, and this was indicated during the enrollment process, then, the facility will be prompted to complete only select questions from the current calendar year’s partial Patient Safety annual survey. The questions that are unable to be answered at the time of enrollment will be grayed out. Your facility will see a partial survey alert in the NHSN application.  You should leave the alert unresolved until you have data to report. We advise facilities to return to the survey in 6 months to update. For the facility to calculate an SIR, you will need to resolve the Partial survey alert. At the start of the calendar year following when a facility enrolled in NHSN, they will have to complete the same annual survey, but at this time, they will have to complete all the questions. For example, if your facility enrolled in NHSN during 2020, but was not operational in 2019, you will complete a partial 2020 PSC annual survey containing basic facility characteristic questions. In the next calendar year, 2021, you will have to complete the entire 2020 PSC annual survey with the data for your facility from the 2020 calendar year. 

If operational in the prior year:  

If your facility was operational during the prior calendar year, and this was indicated during enrollment, then the facility will be prompted to complete a full PSC annual survey. For example, if your facility enrolled during 2020 and was operational for 2019, then you will complete a full version of the 2019 PSC annual survey; all questions will be required.  

You should use the checkbox only if your facility or CMS IRF unit was NOT operational in the prior year, no monthly reporting plans were submitted for that year, and no HAI data (including summary data, device days, events or procedures data) was entered for the prior year. 

At this time, no annual surveys are required to participate in the HCP Influenza Vaccination module. However, NHSN encourages users to complete the (optional) “Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel”. The data collected in this brief survey, including methods a facility uses to deliver influenza vaccine to its HCP, are very helpful to CDC personnel.  If you elect to complete this survey, only one survey should be completed during the influenza season. More information on the survey can be found here: Surveillance for Healthcare Personnel Vaccination.

Patient Safety annual facility surveys must be completed and saved to your NHSN account no later than March 1st of each calendar year. Failure to save a survey to NHSN by this date will result in future monthly reporting plans to be locked for editing until the most recent survey is completed.

All PSC Annual Surveys can be edited at any time in NHSN. Please remember survey data is used for risk adjustment calculations that are used in generating SIRs. Changes to these values may change your SIR. Data that has been submitted to CMS Inpatient Quality Reporting will not be re-submitted after a deadline has passed even if edited survey data changes your facility’s SIR.

To collect admissions data by birthweight category, we suggest first speaking to the NICU Medical Director or Nursing Director, as they are usually familiar with such data and how to access it. If neither can assist, try asking Quality Data Analysts in either the NICU or the hospital. They often can access admissions data by birthweight. These analysts may have different names in different hospitals and are usually part of a larger department available to assist with data needs.

Hospitals providing any level of neonatal care are required to complete neonatal-specific survey questions. Hospitals that provide care to well newborns, but do not have a Level II or higher neonatal unit will record 0 admissions for the question, “Excluding Level I units (well newborn nurseries), record the number of neonatal admissions to Special Care Nurseries (Level II) and Intensive Care Units (Level II/III, Level III, Level IV),” on the Hospital Survey.

No. These questions are asking hospitals to report the number of annual admissions. Additional data collection may be required to determine the number of annual admissions by birthweight category, but only report admissions and not patient days.

• Outborn admission: admission of an infant delivered outside of your hospital.
• Inborn admission: admission of an infant delivered inside of your hospital.

These questions are asking about the weight of the infant at birth.