Draft dQM CMS Content Implementation Guide
2025.1.0 - CI Build

Draft dQM CMS Content Implementation Guide, published by cqframework. This guide is not an authorized publication; it is the continuous build for version 2025.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/dqm-content-cms-2025/ and changes regularly. See the Directory of published versions

Library: TJCOverall

Official URL: https://madie.cms.gov/Library/TJCOverall Version: 9.1.000
Active as of 2025-08-25 Responsible: The Joint Commission Computable Name: TJCOverall

Common functions and definitions used by TJC measures

Metadata
Title TJCOverall
Version 9.1.000
Topic FHIR
Topic CQL
Steward (Publisher) The Joint Commission
Description

Common functions and definitions used by TJC measures
Type logic-library from http://terminology.hl7.org/CodeSystem/library-type
Dependency Description: Model USQualityCore
Resource: https://madie.cms.gov/Library/USQualityCore-ModelInfo|0.1.0-cibuild
Canonical URL: https://madie.cms.gov/Library/USQualityCore-ModelInfo|0.1.0-cibuild
Dependency Description: Library FHIRHelpers
Resource: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1
Canonical URL: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1
Dependency Description: Library FHIRCommon
Resource: http://hl7.org/fhir/uv/cql/Library/FHIRCommon|2.0.0
Canonical URL: http://hl7.org/fhir/uv/cql/Library/FHIRCommon|2.0.0
Dependency Description: Library USCoreCommon
Resource: http://hl7.org/fhir/us/cql/Library/USCoreCommon|2.0.0-ballot
Canonical URL: http://hl7.org/fhir/us/cql/Library/USCoreCommon|2.0.0-ballot
Dependency Description: Library USCoreElements
Resource: http://hl7.org/fhir/us/cql/Library/USCoreElements|2.0.0-ballot
Canonical URL: http://hl7.org/fhir/us/cql/Library/USCoreElements|2.0.0-ballot
Dependency Description: Library CQMCommon
Resource: CQMCommonversion: null5.1.000)
Canonical URL: https://madie.cms.gov/Library/CQMCommon|5.1.000
Dependency Description: Library USQualityCoreCommon
Resource: US Quality Core Commonversion: null0.1.0-cibuild)
Canonical URL: https://madie.cms.gov/Library/USQualityCoreCommon|0.1.0-cibuild
Dependency Description: Value Set Comfort Measures
Resource: Comfort Measures
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/1.3.6.1.4.1.33895.1.3.0.45
Dependency Description: Value Set Discharge To Acute Care Facility
Resource: Discharge To Acute Care Facility
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.87
Dependency Description: Value Set Discharged to Health Care Facility for Hospice Care
Resource: Discharged to Health Care Facility for Hospice Care
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.207
Dependency Description: Value Set Discharged to Home for Hospice Care
Resource: Discharged to Home for Hospice Care
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.209
Dependency Description: Value Set Ischemic Stroke
Resource: Ischemic Stroke
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.247
Dependency Description: Value Set Left Against Medical Advice
Resource: Left Against Medical Advice
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.308
Dependency Description: Value Set Nonelective Inpatient Encounter
Resource: Nonelective Inpatient Encounter
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.424
Dependency Description: Value Set Patient Expired
Resource: Patient Expired
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.309
Data Requirement Type: Encounter
Profile(s): Encounter
Code Filter(s):
Path: type
ValueSet: Nonelective Inpatient Encounter
Data Requirement Type: ServiceRequest
Profile(s): ServiceRequest
Code Filter(s):
Path: code
ValueSet: Comfort Measures
Data Requirement Type: Procedure
Profile(s): Procedure
Code Filter(s):
Path: code
ValueSet: Comfort Measures
Parameters
Name Use Card. Type Documentation
Measurement Period In 0..1 Period
Patient Out 0..1 Resource
Non Elective Inpatient Encounter With Age Out 0..* Encounter
Ischemic Stroke Encounter Out 0..* Encounter
Ischemic Stroke Encounters With Discharge Disposition Out 0..* Encounter
Intervention Comfort Measures Out 0..* Resource
Encounter With Comfort Measures During Hospitalization Out 0..* Encounter
Library Content
CQL Content 
/*
@description: TJCOverall Common Functions

NOTE: This library is not published in this IG, it is included here for convenience. The source of truth for
this library will be the MADiE environment once it fully supports use of QICore STU6-derived.
*/
library TJCOverall version '9.1.000'

using USQualityCore version '0.1.0-cibuild'
using USCore version '6.1.0-derived'
using FHIR version '4.0.1'

include hl7.fhir.uv.cql.FHIRHelpers version '4.0.1' called FHIRHelpers
include hl7.fhir.uv.cql.FHIRCommon version '2.0.0' called FHIRCommon
include hl7.fhir.us.cql.USCoreCommon version '2.0.0-ballot' called USCoreCommon
include hl7.fhir.us.cql.USCoreElements version '2.0.0-ballot' called USCoreElements

include CQMCommon version '5.1.000' called CQMCommon
include USQualityCoreCommon version '0.1.0-cibuild' called USQualityCoreCommon

valueset "Comfort Measures": 'http://cts.nlm.nih.gov/fhir/ValueSet/1.3.6.1.4.1.33895.1.3.0.45'
valueset "Discharge To Acute Care Facility": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.87'
valueset "Discharged to Health Care Facility for Hospice Care": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.207'
valueset "Discharged to Home for Hospice Care": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.209'
valueset "Ischemic Stroke": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.247'
valueset "Left Against Medical Advice": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.308'
valueset "Nonelective Inpatient Encounter": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.424'
valueset "Patient Expired": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.309'

parameter "Measurement Period" Interval<DateTime>
  default Interval[@2026-01-01T00:00:00.000Z, @2027-01-01T00:00:00.000Z)

context Patient

define "Non Elective Inpatient Encounter With Age":
  ["Encounter": "Nonelective Inpatient Encounter"] NonElectiveEncounter
        where AgeInYearsAt(date from start of NonElectiveEncounter.period ) >= 18
         and NonElectiveEncounter.period ends during day of "Measurement Period"

define "Ischemic Stroke Encounter":
  "Non Elective Inpatient Encounter With Age" NonElectiveEncounterWithAge
   where NonElectiveEncounterWithAge.hasPrincipalDiagnosisOf("Ischemic Stroke" )

define "Ischemic Stroke Encounters With Discharge Disposition":
  "Ischemic Stroke Encounter" IschemicStrokeEncounter
  let DischDisp: IschemicStrokeEncounter.hospitalization.dischargeDisposition
  	where  DischDisp in "Discharge To Acute Care Facility"
		or DischDisp in "Left Against Medical Advice"
		or DischDisp in "Patient Expired"
		or DischDisp in "Discharged to Home for Hospice Care"
		or DischDisp in "Discharged to Health Care Facility for Hospice Care"			

define "Encounter With Comfort Measures During Hospitalization":
  "Ischemic Stroke Encounter" IschemicStrokeEncounter
    with "Intervention Comfort Measures" ComfortMeasure
     such that Coalesce(start of ComfortMeasure.performed.toInterval(), ComfortMeasure.authoredOn) during IschemicStrokeEncounter.hospitalizationWithObservation()

define "Intervention Comfort Measures":
  ( ["ServiceRequest": "Comfort Measures"] ComfortCare
    where ComfortCare.status in { 'active', 'completed', 'on-hold' }
      and ComfortCare.intent in { 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order' }
  )  
  union ( ["Procedure": "Comfort Measures"] ComfortCarePerformed
        where ComfortCarePerformed.status in { 'completed', 'in-progress' }
  )
  
define fluent function calendarDayOfOrDayAfter(StartValue DateTime):
  Interval [date from (StartValue), date from (StartValue) + 1 day]
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