This page is part of the National Healthcare Safety Network (NHSN) Digital Quality Measure (dQM) Reporting Implementation Guide (v1.0.0-ballot: STU 1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. . 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 defines the following actors. Note, it is possible for a given system to play the role of multiple actors. For example, and EHR could be both the Data Source and dQM Evaluation Engine when calculating a measure internally. Likewise a system residing at NHSN that queries the Data Source remotely, evaluates those data, produces MeasureReport bundles, and validates the result may be both the dQM Evaluation Engine and MeasureReport Recipient.

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

• dQM Evaluation Engine A system that retrieves data from the Data Source and evaluates those data against one or more measures retrieved from the Measure Source. The resulting MeasureReport bundle and related resources are then sent to the MeasureReport recipient The dQM Evaluation Engine acts as a US Core Client, a DEQM Reporter Client, and implements the $evaluation-measure operation

• Data Source A system containing data (typically patient data, but could be situational awareness data) that will be evaluated against one or more measures. This may be a FHIR server, an EHR with a FHIR endpoint (facade), an internal data store when the Data Source and dQM Evaluation Engine actors are played by the same system such as an EHR that does it’s own measure evaluation, or it may be a system containing other data such as situational awareness data that is reporting via CSV or other format. When FHIR enabled, the Data Source acts as a US Core Server

• Data Aggregator For some example use cases, such as bed capacity reporting, data from multiple Data Source actors may be aggregated by a single system before measure evaluation. A Data Aggregator also plays the role of a Data Source once aggregation is complete. An example would be a state public health agency aggregating data from all facilities in the state before using those data to produce a MeasureReport containing bed capacity data for the entire state. When FHIR enabled, a Data Aggregator acts as a US Core Server when playing the role of a Data Source after aggregation. During aggregation, the Data Aggregator acts similar to the SANER options for aggregation, but implements its own CapabilityStatement due to the incompatibilities between DEQM and SANER.

• Measure Source A system at NHSN that stores FHIR resources such as Measure, Library, ValueSet, etc. that are used for dQM Reporting. The dQM Evaluation Engine queries the Measure Source for the latest Measure content before querying the Patient Data Source and performing measure evaluation. The Measure Source acts as a DEQM Publishable Measure Repository

• MeasureReport Recipient A system at NHSN that receives MeasureReport bundles from the dQM Evaluation Engine and validates the result against the profiles in this implementation guide, and potentially other measure-specific profiles that are distributed with the measures themselves (this kind of validation is referred to as “pre-qualification” at NHSN). The MeasureReport Recipient acts as a DEQM Receiver Server, provides write access to Bundle resources containing MeasureReport and other related resources, and implements the $validate operation.

Use Cases

This implementation guide will serve a wide variety of use cases for NHSN. The measures in this IG are examples only and a separate IG will define NHSN specific measures.

Use Case 1: Acute Care Hospital (ACH)

Description

The NHSN Acute Care Hospital (ACH) digital quality measure (dQM) allows facilities to report line-level data electronically to NHSN for the following modules that provide monthly event rates back to the facility such as: Glycemic Control (hyperglycemia and medication-related hypoglycemia); Healthcare facility-onset, antibiotic-Treated Clostridioides difficile (C. difficile) Infection (HT-CDI); Hospital-Onset Bacteremia & Fungemia (HOB), Venous Thromboembolism (VTE)-related prophylaxis and event rates (under development), Late Onset Sepsis / Meningitis (under development), Hospital-onset Acute Kidney Injury (HAKI) (under development), and Opioid-related Adverse Events (ORAE) (under development). NHSN protocols for these measures will soon be available at https://www.cdc.gov/nhsn/acute-care-hospital/index.html.

Patients of Interest

The facility will work with NHSN to define a list of patients of interest(POI list). This is often the entire in-patient 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).

Initial Population

The initial population in the ACH 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, benchmark and or stratify the individual protocol measures is submitted to NHSN.

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 Initial Population Library (CQL) Example ACH Measure Library

ACH Submission Examples

Bundle Submission Examples

• Full Submission Bundle
• Submitting Organization
• Submitting Device

POI List

• ACH Patients Of Interest

Subject List Measure Report

• ACH Subject List

Individual Measure Report

• ACH Individual Measure Report List

Initial Population Examples

Patient

• Patient - Example Sameresultdiffday

Encounter

• Encounter - Example ACH Pass2 - Inpatient
• Encounter - Example ACH Pass2 - Emergency
• Encounter - Example ACH Pass3 - Short Stay
• Encounter - Example ACH Pass3 - Acute

Line Level Data Examples

Condition

• Condition - Example Diagnosis ACH Pass1 Encounter Diagnosis
• Condition - Example Diagnosis ACH Pass2 Problem List

Coverage

• Coverage - Example ACH Pass1 Medicaid
• Coverage - Example ACH Pass2 Commercial

Device

• Device - Example ACH Pass1 Central Line

Diagnostic Report

• DiagnosticReport - Example ACH Pass2 Cardiopulmonary1
• DiagnosticReport - Example ACH Pass2 Lab CBC

Location

• Location - Example ACH - Emergency
• Location - Example ACH - Inpatient
• Location - Example ACH - Nicu

Medication

• Medication - Example Heparin
• Medication - Example Metformin 1000
• Medication - Example Vancomycin 15
• Medication - Example Insulin Lispro

Medication Administration

• MedicationAdministration - Example ACH Pass2 Heparin 1
• MedicationAdministration - Example ACH Pass2 Heparin 2
• MedicationAdministration - Example ACH Pass2 Insulin Lispro 1
• MedicationAdministration - Example ACH Pass2 Insulin Lispro 2

Medication Request

• MedicationRequest - Example ACH Pass1 Vancomycin
• MedicationRequest - Example ACH Pass2 Metformin

Observation

• Observation - Example ACH Pass1 Blood
• Observation - Example ACH Pass1 Csf
• Observation - Example ACH Pass1 Gestational Age
• Observation - Example ACH Pass1 Vitals Weight
• Observation - Example ACH Pass2 Hemo A1C
• Observation - Example ACH Pass3 C. diff

Procedure

• Procedure - Example ACH Pass1 Central Line
• Procedure - Example ACH Pass1 Lumbar

Service Request

• ServiceRequest - Example ACH Pass1 Blood
• ServiceRequest - Example ACH Pass1 CSF
• ServiceRequest - Example ACH Pass2 Glucose
• ServiceRequest - Example ACH Pass2 Hemo A1C
• ServiceRequest - Example ACH Pass3 Cdiff

Specimen

• Specimen - Example ACH Pass1 Blood
• Specimen - Example ACH Pass1 CSF
• Specimen - Example ACH Pass3 Stool

Use Case 2: Bed Capacity Reporting

Description

The NHSN Bed Capacity measure allows for facilities to report real-time hospital bed capacity data electronically to CDC’s National Healthcare Safety Network (NHSN), enabling a jurisdictional capacity datastore and dashboard for viewing real-time occupancy information. The goal of this measure is to strengthen healthcare systems capacity by providing near real time insight into routine operations and especially during public health emergencies.

The NHSN Bed Capacity use case is intended to follow the pattern of a SANER measure, but there are currently incompatibilies between SANER and DEQM that the owning HL7 work groups have agreed to resolve, but have not yet implemented. Once SANER and DEQM are harmonized this IG will likely be updated to reflect that.

Background

Formally called the NHSN Connectivity Initiative: Hospital Bed Capacity Project, the objective of this measure is to establish a web-based easy-to use interface to be accessed by hospitals and governmental agencies at a state and regional level to coordinate daily, surge and crisis needs. Since March 2020, the U.S. government has been consistently collecting data from hospitals and states to better understand healthcare system stress, capacity, capabilities, and hospitalizations. The COVID-19 pandemic underscored the Federal needs for data are continuously evolving, and that data modernization must be prioritized to reduce burden and maximize efficiency.

Bed Inclusion Criteria

For all bed censuses and counts, the following bed types should be included:

1. All inpatient staffed and unblocked beds
2. Observation beds

Bed Exclusion Criteria

For all bed censuses and counts, the following bed types should be excluded:

1. Virtual beds or locations in the EMR that are not physical spaces (i.e., beds used for interoperative phase of care or in certain operative settings or virtual staging areas for admissions.)
2. Beds no longer in use, even in case of surge
3. Blocked beds (i.e., beds blocked due to logistical or maintenance challenges, staffing restrictions, isolation, etc.)

Unit Inclusion Criteria

• ED Emergency department
• ICU Intensive care unit
• LOC Level of care
• MT/MS Medicine telemetry/medicine surgery acute care bed
• NICU Neonatal intensive care unit
• NP Negative pressure
• OB Obstetrics
• OBS Observation
• PCU Progressive care unit
• Peds Pediatric
• PICU Pediatric intensive care unit
• Psych Psychiatric
• Rehab Rehabilitation

Bed Capacity Examples

• MeasureReport - Children’s Hospital Bed Capacity Individual Measure Report
• MeasureReport - Hospital Bed Capacity Individual Measure Report
• MeasureReport - Inpatient Psychiatric Facility Bed Capacity Individual Measure Report