Healthcare Associated Infections (HAIs) Reporting
Whether you are new to HAI reporting for Texas or you need help with your current reporting, this is the place for you! Here you can find information on the Texas Reporting Requirements and get help navigating the National Healthcare Safety Network (NHSN) and the Texas Healthcare Safety Network (TxHSN).
HAI Reporting Requirements
Chapter 98 of the Texas Health and Safety Code, (Reporting of Health Care-Associated Infections and Preventable Adverse Events), and 25 Texas Administrative Code, Chapter 200 (Health Care-Associated Infections) requires the Texas Department of State Health Services to establish the Texas HAI Reporting System. These were created to provide the public with HAI data and to support quality improvement and infection control activities in health care facilities. Below is a list of HAIs that are required to be reported by Texas General Hospitals. Starting January 1, 2020, ambulatory surgery centers (ASCs) were no longer required to report HAI data.
Texas Reportable HAIs (as of January 1, 2020)
|Central line-associated bloodstream infections (CLABSI)||All ICUs (& NICUs), Medical Wards, Surgical Wards and Medical/Surgical Wards|
|Catheter associated urinary tract infections (CAUTI)||All ICUs (not NICUs), Medical Wards, Surgical Wards and Medical/Surgical Wards|
|Abdominal Hysterectomies (HYST) SSIs||Inpatient|
|Colon Surgery (COLO) SSIs||Inpatient|
|Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteremia Laboratory Identified Events||Facility Wide (Inpatient)|
|Clostridioides difficile Infection Laboratory Identified Events||Facility Wide (Inpatient)|
Below is a table showing the reporting schedule. It indicates major deadlines associated with reporting HAI data to Texas.
|Q1: Jan. 1 - Mar. 31||H1: Jan. 1 - Jun. 30||Q3: Jul. 1 - Dec. 31||H2: Jul. 1 - Dec. 31|
|Facility data submission deadline||Within 60 days of end of reporting quarter|
|DSHS takes preliminary data snapshot||1-Jun||1-Sept||1-Dec||1-Mar|
|DSHS sends email to facility users to review data||~15-Jun||~15-Sep||~15-Dec||~15-Mar|
|Facility data corrections due||30-Jun||30-Sep||31-Dec||31-Mar|
|DSHS takes final snapshot||1-Jul||1-Oct||1-Jan||1-Apr|
|DSHS sends email to facility to review data
summary and make comments
|Facility comment period deadline||NA||30-Oct||NA||30-Apr|
|DSHS reviews comments||NA||15-Nov||NA||15-May|
|Public posting of data summary with
Getting Started with NHSN
All facilities are required to report their health care associated infection (HAI) data through the National Healthcare Safety Network (NHSN). Below is a list of steps to help guide facilities through this process.
- NHSN Enrollment
The first step in HAI reporting is to enroll your facility in NHSN. To do this, follow the instructions linked below for your facility type.
NOTE: Facilities with more than one campus at different physical locations must enroll each campus location separately, unless connected by a skybridge or other physical connector. This is regardless of whether the campuses all share a CMS or other license number.
NOTE: If you cannot register your facility with your CMS Certification Number or your AHA number, you can request a temporary CDC Registration ID by emailing NHSN@cdc.gov and requesting one.
Instructions for General Hospitals
Instructions for Ambulatory Surgery Centers
- Setting up your facility
Once your facility is enrolled in NHSN, you must perform some set-up steps like adding additional users, locations within your facility (if you are a general hospital), and you can add surgeons if you want to (surgeon info will not be sent to DSHS).
- Conferring Rights
In order for Texas to have access to your data in NHSN, you must join the appropriate HAI Reporting group in NHSN and accept the confer rights template. To do this, follow the instructions for your facility type. Please note that the only user that can complete this process is the NHSN Facility Administrator (usually the person who enrolled your facility in NHSN). For questions, please email email@example.com.
Instructions for General Hospitals: Texas Hospital Confer Rights (PDF)
Instructions for ASCs: Texas ASC Confer Rights Instructions (PDF)
NHSN Facility Users
Once you have enrolled and accepted the confer rights template, you can add additional users for your NHSN facility. To do this, your NHSN Facility Administrator (usually the person who enrolled your facility in NHSN) will need to add you as a Facility User. The Facility Administrator can do this in NHSN, under the User page.
Once this happens, the new user must follow the steps provided on the CDC NHSN Group Users webpage.
NOTE: If you are the current NHSN Facility Administrator and are leaving your facility, you must re-assign the Facility Administrator role to another user.
NOTE: If the NHSN Facility Administrator leaves without reassigning the administrator role to another user, the facility will need to send a letter from an “O” suite administrator on company letterhead indicating that they need NHSN to manually change the administrator.
Set up your Texas Health Care Safety Network (TxHSN) users: See steps below in the “Getting started with TxHSN” section. Texas Healthcare Safety Network (TxHSN) was developed to help coordinate & simplify the communication process between Texas and reporting healthcare facilities. It is a web-based application that facility contacts will be able to log into to view reports and make comments about their HAI data.
The diagram above shows how the general reporting process will work. Each healthcare facility will login to NHSN (the National Healthcare Safety Network) and enter all applicable HAI data. DSHS will have rights to pull your data from NHSN. The data that DSHS gets from NHSN will then be stored in TxHSN and facility-specific reports will be generated there. TxHSN will email facility contacts to notify them that their reports are ready to view in TxHSN. The facility contacts will then log into TxHSN and run reports as instructed and comment on data as they see fit.
TxHSN Designated Contacts
Each facility is allowed up to two designated HAI contacts. These contacts are the individuals responsible for communicating with DSHS, reviewing reports and making comments on the Facility HAI reports that will be available to the public.
In order to keep our records up to date with the most current contact information, letters to each facility’s CEO will be sent out annually. This letter will request information regarding whether the facility is required to report and who should be designated as the TxHSN contacts.
It is EXTREMELY important that the contact information we have for your facility is correct. If either of these contacts changes, complete this Contact Change Form and return by fax to 512-776-7616 or email to firstname.lastname@example.org. Please let us know as soon as possible so we can update your facility’s user accounts appropriately.
What is the TxHSN Internal Data Review Report?
The TxHSN Internal Data Review Report shows the number of records that were submitted to NHSN for each record type for a given reporting time period. This report shows the total number of Event (infection) records (CLABSIs, CAUTIs and SSIs) and Procedure records that we have pulled from NHSN for your facility. Total numbers of each record type are shown in the first table. The following tables show the number of records reported by unit type or procedure type and year/month. Please verify these record counts to make sure all of your HAI records have been reported to Texas.
NOTES: This report will only count records for which your facility has conferred rights to Texas to view.
To run your Internal Data Review Report:
Log on to TxHSN to run your Internal Data Review Report. to run your Internal Data Review Report.
- Open your Facility Record
Once you have logged in to TxHSN, open your Facility Record. Look for your Facility Record listed in the box labeled "Recent Records".
If your Facility Record is listed under "Recent Records", click on the ID number next to the facility name. This will open your Facility Record.
If your Facility Record is not listed under “Recent Records” you will need to search for your record before you can open it. To search for your Facility Record, click the Search Record icon in the upper left corner of the screen. The icon looks like a magnifying glass. This will open a new Search page. On the Search page, find the field labeled "Record Type" located about halfway down the page. Choose "Facility" for the Record Type. Click the gray button labeled "Search" at the bottom of the page. Your facility name should appear in the Search Results table on the right side of the page. Double-click on the name of your facility. This should open your Facility Record.
- Run your Internal Data Review Report
Now that you have opened your Facility Records, you can access your Internal Data Review Report by clicking on the “Internal Data Review Report” link located in the top half of the page, next to the box labeled "Facility Links". This will take you to a new page labeled "TxHSN Reporting". Click on the "Run Report" button on the TxHSN Reporting page. Your Internal Data Review should open in a new window. Please note the facility name and "Data current as of" date in the heading of the report. You can print the report for your records.
How do I preview the Facility HAI Reports?
- Open your Facility Record. Once you have logged in to TxHSN, open your Facility Record. Look for your Facility Record listed in the box labeled "Recent Records." If your Facility Record is listed here, click on the ID number next to the facility name. This will open your Facility Record. If your Facility Record is not listed in Recent Records, you will need to search for it. To search for your Facility Record, click the Search Record icon in the upper left corner of the screen. The icon looks like a magnifying glass. This will open a new Search page. On the Search page, find the field labeled "Record Type" located about halfway down the page. Choose "Facility" for the Record Type (if it is not already selected for you). Click the button labeled "Search" at the bottom of the page. Your facility name should appear in the Search Results table on the right side of the page. Double-click on the name of your facility. This should open your Facility Record.
How do I submit a comment regarding my Facility HAI Report?
If you wish, you may submit a comment to add to your facility's HAI Reports. This comment will appear at the bottom of both versions of the report for the public to view. Please note that DSHS does not have expectations for the content of these comments. Please review the general guidelines below.
Open your Facility Record: See the instructions above on how to open your Facility Record.
- Open the "Facility Comment Tracking" question package. With your Facility Record open, find the question package labeled "Facility Comments Tracking." This is located toward the middle of the page, under the box labeled "Record Data." Open the "Facility Comment Tracking" by double-clicking on it. You can also click to highlight the line in yellow, then click "View Question Package" button toward the bottom of the page.
- Enter your Comment. Now that you are viewing the Facility Comments Tracking page, locate the section on the page with the appropriate Reporting Time Period. Find the box with the message "Enter comments regarding your facility's Data Display Report here:" Follow the instructions on the screen.
- Submit your Comment to DSHS for review. All comments must be entered and submitted to DSHS by the deadline provided (see Texas Reporting Timeline). Once you have entered your comment, click anywhere outside the comments box to refresh the page. A new question will appear that says "Submit comment to DSHS for review?" Please read carefully: If you wish to edit your comment again before submitting to DSHS, choose "No" for this question. If you are finished editing the comment, choose "Yes" for this question. You will not be able to change your comment once it has been submitted. Only comments that are submitted to DSHS are eligible to appear on the public Facility HAI Reports. Only DSHS approved comments will be visible on the public Facility HAI Reports.
- Click the "Save" button at the top of the screen to save any changes you made. You can now exit the Facility Record by clicking “X” in the top right corner of the page. You can log back in to TxHSN in 2-4 days to see if your comment has been approved by DSHS.
Additional Instructions and Information:
You are not required to submit a comment. Please do NOT enter and submit a comment that says, "No comment." Comments will not be approved if they contain any of the following:
- Inappropriate language
- References to another health care facility
- Do not reflect the current reporting time period
- Were submitted after the Facility Comments Deadline
DSHS will review your facility comment for approval. These reports will be posted for the public to view.
Run your Detailed Facility HAI Report. You can now access Detailed Facility HAI Report by clicking on the “Detailed Facility HAI Report” link located in the top half of the page, next to the box labeled "Facility Links". This will take you to a new page labeled "TxHSN Reporting". On the TxHSN Reporting page, click on the "Run Report" button. Your Detailed Facility HAI Report should open in a new window. Please note the facility name and "Data current as of" date in the heading of the report. You may want to print the report for your records.