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State of California—Health and Human Services Agency
California Department of Public Health

AFL 07-37
November 27, 2007

General Acute Care Hospitals

Mandated Use of the National Health and Safety Network to Comply with Senate Bill 739 on the Reporting of Hospital Acquired Infections Process Measures


Chief Executive Officer
Infection Control Committee Chair
Infection Prevention and Control Professionals



Senate Bill (SB) 739 (Speier, Statutes of 2006)
California Code of Regulations, Title 22, §70739



This is a follow-up letter to AFL 07-06 “Compliance with Senate Bill 739 on Hospital-Acquired Infections (HAIs),” dated March 1, 2007. Please review and share this document with all persons in your facility responsible for infection prevention and control activities.

SB 739 requires that, on and after January 1, 2008, all general acute care hospitals report to the California Department of Public Health (CDPH) the following process measures: 1) central line insertion practices, 2) influenza vaccination of employees and patients, and 3) surgical antimicrobial prophylaxis. SB 739 also requires each hospital to submit data on implemented process measures to the National Healthcare Safety Network (NHSN) of the Centers for Disease Control and Prevention (CDC), or to any other scientifically valid national HAI reporting system based upon the recommendation of the CDC. At present there is no national HAI reporting system other than the NHSN.

To comply with these reporting requirements, the California Healthcare-Associated Infections Advisory Committee (HAI-AC) has recommended the use of the National Health and Safety Network (NHSN) reporting software. In concurrence with this recommendation, the CDPH Licensing and Certification Program now requires that all general acute care hospitals use NHSN for reporting to CDPH the SB 739 mandated measures that are available through NHSN. For those measures not available through NHSN on January 1, 2008, (as anticipated for surgical antimicrobial prophylaxis) recommendations for alternative reporting methods, for example the Surgical Care Improvement Project through the Centers for Medicare & Medicaid Services, will be forthcoming.

NHSN is a reporting system started in 2005 as the successor to the U. S. Centers for Disease Control and Prevention (CDC)’s National Nosocomial Infections Surveillance (NNIS) program. Reporting through NHSN enables monitoring of healthcare-associated events and processes and integrates three CDC patient and healthcare personnel safety surveillance systems onto a single internet platform. More information on NHSN is available at CDC-NHSN. Four states currently require enrollment in NHSN for reporting purposes and over 800 hospitals are enrolled nationwide. There is no monetary cost to join NHSN.


Enrollment in National Reporting System (per SB 739)

Hospitals should enroll now. Please follow these steps.

  1. Designate a facility administrator who will have access to all infection control-related data and be assigned full rights. Forward this name and contact information to Sue Chen (email address below).
  2. All persons who need access to the data should apply for their own digital certificate. Note that up to 16 hours of training is required to obtain a digital certificate.

Here are the steps for obtaining a digital certificate.

  1. Log on to NHSN Log-in.
  2. Accept the rules of behavior.
  3. Complete 8 web-archived modules (approximately 2 hours each). Webinars can be viewed from any computer; multiple staff can view them at the same time.
  4. Review other documents as required.
  5. Apply for the digital certificate (more detailed instructions are on the website). The digital certificate must be installed on the participant’s primary computer.
  6. Designate CDPH as your “group.” You may also be a part of other groups (such as a hospital system group) for purposes of data aggregation or comparison.
  7. Give CDPH permission to see mandated process measures.

Note: Information Technology (IT) may need to relax your facility’s firewall to enable the downloading of the certificate, data, and educational materials for compliance with this directive.

The specific process measure modules for central line insertion procedures and influenza immunization of employees and patients have not yet completed the CDC clearance process. Clearance is anticipated by January 1, 2008. At that time, supporting educational modules will be released and must be completed by certificate holders. The Department will notify your hospital of effective dates for actual data collection and reporting to NHSN.

For questions, the point of contact at CDPH is Sue Chen, HAI-Program Coordinator at or phone (510) 620-3434.



Original Signed by Kathleen Billingsley, R.N.

Kathleen Billingsley, R.N.
Deputy Director
Center for Healthcare Quality


California Hospital Association
California Conference of Local Health Officers
CDPH Emergency Preparedness Office
CDPH Licensing and Certification Program
CDPH Division of Communicable Disease Control
HAI Advisory Committee 

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