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        CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
        1.0.0 - Release 1 United States of America flag

        This page is part of the CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG (v1.0.0: Release) based on FHIR (HL7? FHIR? Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

        Actors and Use Cases

        Page standards status: Informative

        Actors

        This implementation guide (IG) defines the following actors: a data source, a dQM evaluation engine, a measure source, and a data aggregator.

        Note: A given system may play the role of multiple actors. For example, an electronic health record (EHR) could serve as both the data source and dQM evaluation engine when calculating a measure internally. Likewise, a system such as NHSNLink, which resides at the National Healthcare Safety Network (NHSN) and queries the data source remotely may act as the dQM evaluation engine and MeasureReport recipient, evaluating the data, producing, and validating MeasureReport bundles.

        The actors defined here are used in the Reporting Scenarios section of the Specification page in this IG.

        • Data Source: The EHRs for facilities reporting to NHSN serve as the data source.
        • Measure Source: NHSN stores Fast Healthcare Interoperability Resources (FHIR) resources used for dQM reporting, such as Measure, Library, ValueSet, etc. that systems can query for the latest measure content before querying the EHR FHIR server and performing measure evaluation.
        • dQM Evaluation Engine: Requests and queries patients from the EHR FHIR server and evaluates the data against the dQM retrieved from the Measure Source. The dQM evaluation engine validates the data against the profiles in this IG.
        • MeasureReport Recipient: NHSN ingests the MeasureReport bundles from the dQM evaluation engine.

        Use Cases

        This IG serves a wide variety of NHSN use cases.

        Use Case 1: Acute Care Hospital (ACH) Monthly

        ACH Monthly Description

        The NHSN ACH Monthly dQM enables facilities to electronically report line-level data to NHSN for the following modules, which provide monthly event rates back to the facility. These dQMs include:

        • Glycemic Control (includes hyperglycemia and medication-related hypoglycemia events)
        • Bacteremia & Fungemia Surveillance (includes Hospital-Onset Bacteremia & Fungemia events)
        • Clostridioides difficile Surveillance (includes Healthcare facility-onset, antibiotic-Treated CDI events)
        • Sepsis Surveillance (includes Adult Community-onset Sepsis events)
        • Venous Thromboembolism (VTE)-related Prophylaxis and event rates (under development)
        • Late-Onset Sepsis / Meningitis (LOS/MEN) (under development)
        • Hospital-onset Acute Kidney Injury (HAKI) (under development)
        • Opioid-related Adverse Events (ORAE) (under development)

        ACH Monthly Patients of Interest

        The facility works with NHSN to define a patients of interest (POI) list. The POI list is often the facility’s entire Inpatient, Emergency, and Observation population. The data for the patients on the list are then extracted and evaluated against the measure criteria for the initial population.

        ACH Monthly Initial Population

        The initial population in the ACH Monthly dQM is defined as all encounters for patients of any age in an Emergency Department (ED), observation, or inpatient location or all encounters for patients of any age with an ED, observation, inpatient, or short stay status during the measurement period. Once an individual patient meets the population criteria, the line-level data needed to calculate metrics, to benchmark, and/or to stratify the individual protocol measures is submitted to NHSN.

        ACH Monthly Additional Use Case Information References

        For specific information on the individual NHSN protocols and metrics see: Acute Care / Critical Access Hospitals (ACH) | NHSN | CDC Example ACH Monthly Initial Population Library (CQL) Example ACH Monthly Measure Library

        ACH Monthly Submission Examples

        ACH Monthly Bundle Submission Examples

        ACH Monthly POI List

        ACH Monthly Subject List Measure Report

        ACH Monthly Individual Measure Report

        ACH Monthly Initial Population (IP) Examples

        ACH Monthly IP Patient Examples
        ACH Monthly IP Encounter Examples

        ACH Monthly Line Level Data Examples

        ACH Monthly IP Condition Examples
        ACH Monthly IP Coverage Examples
        ACH Monthly IP Diagnostic Report Examples
        ACH Monthly IP Location Examples
        ACH Monthly IP Medication Examples
        ACH Monthly IP Medication Administration Examples
        ACH Monthly IP Medication Request Examples
        ACH Monthly IP Observation Examples
        ACH Monthly IP Procedure Examples
        ACH Monthly IP Service Request Examples
        ACH Monthly IP Specimen Examples

        Use Case 2: ACH Daily

        ACH Daily Description

        The NHSN Respiratory Pathogens Surveillance (RPS) module enables the measurement of facility and unit-specific incidence and prevalence of Coronavirus 2019 (COVID-19), Influenza, and Respiratory Syncytial Virus (RSV) disease among patients admitted to the hospital (inpatient, observation, or short stay status), and specific associated patient outcomes. The RPS module offers a mechanism for ongoing monitoring of infectious respiratory viral illness among hospitalized patients with minimal human resource expenditure via 100% electronically automated data capture. This initial version of the module is based on electronic data capture and upload of demographic, administrative, and clinical data from the facility’s electronic source systems such as the EHR, patient registration system (admission, discharge, and transfer [ADT] data), laboratory information system, and pharmacy electronic medication administration system.

        RPS module data collected via the ACH Daily dQM may be used by facilities for quality improvement and patient care planning purposes, as well as by local, state, and federal public health agencies in coordination and response to public health outbreaks. Facilities will have access to their data via the analysis functions of NHSN.

        ACH Daily Patients of Interest

        The facility will work with NHSN to define a POI list. This is often the entire inpatient, observation, or short stay population at the facility. The data for the patients in the list are then extracted and evaluated against the measure criteria for the initial population (see below).

        ACH Daily Initial Population

        The ACH Daily Initial Population includes all encounters with an inpatient, observation, or short stay status for patients of any age during the measurement period.

        ACH Daily Additional Use Case Information References

        http://www.cy118119.com/nhsn/acute-care-hospital/index.html

        ACH Daily Submission Examples

        ACH Daily Bundle Submission Examples

        ACH Daily POI List

        ACH Daily Subject List Measure Report

        ACH Daily Individual Measure Report

        ACH Daily Initial Population Examples

        ACH Daily IP Patient Examples
        ACH Daily IP Encounter Examples

        ACH Daily Line Level Data Examples

        ACH Daily IP Diagnostic Report (Lab) Examples
        ACH Daily IP Lab Result Observation Examples
        ACH Daily IP Location Examples
        ACH Daily IP Medication Examples
        ACH Daily IP Medication Administration Examples
        ACH Daily IP Medication Request Examples
        ACH Daily IP Observation Examples
        ACH Daily IP Procedure Examples
        ACH Daily IP Service Request Examples
        ACH Daily IP Specimen Examples

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