CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
1.0.0 - Release 1
CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
1.0.0 - Release 1
CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Page standards status: Informative |
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.
This IG serves a wide variety of NHSN use cases.
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:
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.
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.
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
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.
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).
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.
https://www.cdc.gov/nhsn/acute-care-hospital/index.html
