Enrolling an Acute Care Hospital in NHSN: The Five Steps

CDC's National Healthcare Safety Network (NHSN) is the most widely used system in the country for tracking healthcare-associated infections. For an acute care hospital, joining takes five steps. A facility enrolls once: after that, it can add reporting options through its monthly reporting plan or by activating a new component in the NHSN application, without re-enrolling.

At a glance

Step 1: Prepare

• Read the NHSN Facility Administrator Enrollment Guide — or, for critical access hospitals, the Critical Access Hospital Enrollment Guide.
• Complete the Patient Safety Component Annual Facility Survey (form 57.103), using its table of instructions.
• Make sure emails from CDC won't be caught by spam filters.

Step 2: Register the facility

Read and agree to the NHSN Rules of Behavior; you'll then be sent to register the facility electronically. The Facility Contact form can help gather the information beforehand.

Two emails follow: "Welcome to NHSN!" right away, and an "Invitation to Register with SAMS" within 24 hours.

Step 3: SAMS registration and identity proofing

3a. The SAMS invitation contains a link, your user ID (your email address) and a temporary password. Follow the link, log in, register and accept the SAMS Rules of Behavior. You have 30 days from the invitation to finish.

3b. If required, SAMS then emails an "Identity Verification Request." You can verify online through Experian, the newer preferred method, or by submitting documents securely. Follow the instructions for your option carefully to avoid delays.

Step 4: Approval and a login token

When approved, you'll get an email titled "SAMS Activity Authorization," with links to the portal and the application (a separate email for each application you're approved for), plus a welcome email.

NHSN requires strong authentication — a token in addition to your password:

• a soft token: the Entrust Authenticator app on a phone, tablet or computer; or
• a hard token: a physical Entrust grid card mailed to your home, which should arrive within 2 weeks of approval. If it doesn't, contact samshelp@cdc.gov.

Step 5: Enroll and consent

5a. Once your token is set up, log in to SAMS through the multi-factor login and choose "NHSN Enrollment" to enroll electronically in the component you want. The facility administrator and primary contact then receive an "NHSN Facility Enrollment Submitted" email.

5b. Log in to NHSN, open each component, review the "Agreement to Participate and Consent," check "Accept" next to the right contact, and submit. The consent must be accepted within 60 days, or the facility is withdrawn.

After enrolling

Enrollment is complete. Take the NHSN acute care hospital training if you haven't already, and complete NHSN setup, which is required before reporting begins.

Sources

Based on "5-Step Enrollment for Acute Care Hospitals/Facilities," National Healthcare Safety Network, Centers for Disease Control and Prevention; a work of the United States government in the public domain.