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Preparing Your Facility for NHSN FHIR Digital Quality Measure Reporting

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AT A GLANCE

 

  • Prepare Stakeholders: Engage key personnel at your facility for the transition to reporting digital quality measures (dQMs) using Healthcare Level Seven International (HL7®) Fast Healthcare Interoperability Resources® (FHIR®).
  • Appoint a Coordinator: Appoint a staff member to serve as the NHSN dQM Implementation Coordinator to oversee reporting tasks.
  • Task Guide: Use this page as a resource to prepare for reporting dQMs to NHSN and for compliance tasks.
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Preparation for dQM Reporting

As part of the Digital Measure Reporting Plan, the facility will authorize NHSNLink to retrieve data from the designated health system-level FHIR application programming interfaces (APIs) to support transmission and calculation of digital quality measures (dQMs) to NHSN. This process follows established data governance protocols and ensures alignment with privacy and security standards.

To submit FHIR digital quality measures (dQMs) to NHSN via NHSNLink, facilities must ensure their data comply with NHSN’s requirements as specified in the CDC NHSN dQM Content Package IG. Facilities should identify personnel who will serve as the champions or liaisons throughout preparation and implementation. These staff ensure the facility completes the necessary tasks before initial connection with NHSNLink and support the facility’s FHIR connection throughout the reporting process. NHSN will update this list of tasks periodically as we prepare for fully automated data exchange with healthcare facilities.

Key Personnel for Reporting FHIR dQMs to NHSN

Facilities preparing to report FHIR dQMs to NHSN should identify key personnel, including those in the following roles:

NHSN dQM Implementation Coordinator

 

The NHSN dQM Implementation Coordinator is crucial for the success of the facility’s health system in this effort. This individual will:

  • Coordinate with the NHSN Facility Administrator for submission of FHIR dQMs to NHSN.
  • Serve as an educator for key personnel at the facility involved with reporting FHIR dQMs to NHSN
  • Ensure completion of preparation tasks [PDF – 85 KB] to ensure the facility is ready for reporting FHIR dQMs to NHSN.
  • Share feedback with NHSN about the facility’s experience in implementing reporting of FHIR dQMs to NHSN.

Staff and Facility Roles

Staff and Facility Roles

Staff and Facility Roles

Examples of Responsibilities

Examples of Responsibilities

Examples of Responsibilities

NHSN dQM Implementation Coordinator

Staff and Facility Roles

NHSN dQM Implementation Coordinator

  • Become familiar with information available in the NHSN FHIR Portal to support connectivity between your facility’s electronic health data and NHSNLink
  • Invite facility stakeholders to view previously recorded informational sessions provided by NHSN about FHIR dQM reporting
  • Connect with facility stakeholders on their roles and responsibilities in pre-work for NHSN FHIR dQM implementation

Examples of Responsibilities

  • Become familiar with information available in the NHSN FHIR Portal to support connectivity between your facility’s electronic health data and NHSNLink
  • Invite facility stakeholders to view previously recorded informational sessions provided by NHSN about FHIR dQM reporting
  • Connect with facility stakeholders on their roles and responsibilities in pre-work for NHSN FHIR dQM implementation

Executive Suite–Informatics (e.g Chief Health Information Officer, Chief Medical Information Officer, Chief Data Officer, Chief Information Officer)

Staff and Facility Roles

Executive Suite–Informatics (e.g Chief Health Information Officer, Chief Medical Information Officer, Chief Data Officer, Chief Information Officer)

  • Provide approval for preparation to report FHIR dQMs to NHSN
  • Designate individuals and teams that will have oversight of clinical activities related to reporting FHIR dQMs to NHSN dQMs Under Development

Examples of Responsibilities

  • Provide approval for preparation to report FHIR dQMs to NHSN
  • Designate individuals and teams that will have oversight of clinical activities related to reporting FHIR dQMs to NHSN dQMs Under Development

Executive Suite–Quality/Safety (e.g., Chief Quality Officer, Chief Medical Officer)

Staff and Facility Roles

Executive Suite–Quality/Safety (e.g., Chief Quality Officer, Chief Medical Officer)

  • Provide approval for preparation to report FHIR dQMs to NHSN
  • Designate individuals and teams that will have oversight of clinical activities related to reporting FHIR dQMs to NHSN

Examples of Responsibilities

  • Provide approval for preparation to report FHIR dQMs to NHSN
  • Designate individuals and teams that will have oversight of clinical activities related to reporting FHIR dQMs to NHSN

NHSN Facility Administrator

Staff and Facility Roles

NHSN Facility Administrator

  • Review and sign the monthly Digital Reporting Plan
  • Work with IT to ensure the facility’s patient-care locations are all correctly mapped according to NHSN Healthcare Facility Patient Care Location codes (HSLOC)
  • Add new stakeholders who have been identified as critical to FHIR dQM implementation as additional users for the facility in NHSN

Examples of Responsibilities

  • Review and sign the monthly Digital Reporting Plan
  • Work with IT to ensure the facility’s patient-care locations are all correctly mapped according to NHSN Healthcare Facility Patient Care Location codes (HSLOC)
  • Add new stakeholders who have been identified as critical to FHIR dQM implementation as additional users for the facility in NHSN

IT–EHR Vendor Team

Staff and Facility Roles

IT–EHR Vendor Team

Examples of Responsibilities

IT – Laboratory Data Team

Staff and Facility Roles

IT – Laboratory Data Team

  • Ensure laboratory test (including central laboratory and point-of-care) types and results are mapped to LOINC and SNOMED codes, respectively
  • Ensure use of best practices when assigning LOINC and SNOMED codes
  • Ensure the facility has a plan in place to update LOINC and SNOMED codes in the EHR/FHIR server at least annually

Examples of Responsibilities

  • Ensure laboratory test (including central laboratory and point-of-care) types and results are mapped to LOINC and SNOMED codes, respectively
  • Ensure use of best practices when assigning LOINC and SNOMED codes
  • Ensure the facility has a plan in place to update LOINC and SNOMED codes in the EHR/FHIR server at least annually

IT – Medication Data Team

Staff and Facility Roles

IT – Medication Data Team

  • Ensure medication descriptions in the “Medication” FHIR resource are mapped to RxNorm codes
  • Ensure routes of medication administration in the “MedicationAdministration” and “MedicationRequest” resources are mapped to SNOMED codes includes data from third-party pharmacy vendors
  • Ensure the facility has a plan in place to update RxNorm and SNOMED codes in the EHR/FHIR server annually, at a minimum

Examples of Responsibilities

  • Ensure medication descriptions in the “Medication” FHIR resource are mapped to RxNorm codes
  • Ensure routes of medication administration in the “MedicationAdministration” and “MedicationRequest” resources are mapped to SNOMED codes includes data from third-party pharmacy vendors
  • Ensure the facility has a plan in place to update RxNorm and SNOMED codes in the EHR/FHIR server annually, at a minimum

Disclaimer: HL7®, and FHIR® are the registered trademarks of Health Level Seven International and the use of these trademarks does not constitute an endorsement by HL7

FHIR Resources
Digital Quality Measures

Resources to support hospital staff with the implementation of NHSN digital quality measure

FAQs

Answers on how to connect to NHSNLink, data analysis of dQMs and more.

NHSNCoLab

Collaboration between public and private stakeholders to pilot new NHSN reporting measures.

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