Hospital Harm – Falls with Major InjuryFHIR - eCQM QICore Content Implementation Guide v2024.0.0

eCQM QICore Content Implementation Guide, published by cqframework. This guide is not an authorized publication; it is the continuous build for version 2024.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/ecqm-content-qicore-2024/ and changes regularly. See the Directory of published versions

Measure: Hospital Harm – Falls with Major InjuryFHIR

Official URL: https://madie.cms.gov/Measure/CMS1017HHFIFHIR		Version: 0.0.026
Active as of 2026-03-13	Responsible: Centers for Medicare & Medicaid Services (CMS)	Computable Name: CMS1017HHFIFHIR
Other Identifiers: Short Name: CMS1017FHIR (use: usual, ), UUID:6425d5e9-a54b-40e0-a07d-e6e17137871c (use: official, ), UUID:0a959a37-4759-47b6-a71f-62823f9e4dee (use: official, ), Endorser: 4120e (use: official, ), Publisher: 1017FHIR (use: official, )
Copyright/Legal: Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. Mathematica disclaims all liability for use or accuracy of any third-party codes contained in the specifications. LOINC(R) copyright 2004-2024 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation. ICD-10 copyright 2024 World Health Organization. All Rights Reserved.

This ratio measure assesses the number of inpatient hospitalizations where at least one fall with a major or moderate injury occurs among the total qualifying inpatient hospital days for patients aged 18 years and older

UNKNOWN

Title: Hospital Harm – Falls with Major InjuryFHIR

Id: CMS1017HHFIFHIR

Version: 0.0.026

Url: Hospital Harm – Falls with Major InjuryFHIR

Short Name Identifier:

CMS1017FHIR

Version Independent Identifier:

urn:uuid:6425d5e9-a54b-40e0-a07d-e6e17137871c

Version Specific Identifier:

urn:uuid:0a959a37-4759-47b6-a71f-62823f9e4dee

Endorser (CMS Consensus Based Entity) Identifier:

4120e

Publisher (CMS) Identifier:

1017FHIR

Effective Period: 2026-01-01..2026-12-31

Publisher: Centers for Medicare & Medicaid Services (CMS)

Author: Mathematica

Description:

Purpose:

UNKNOWN

Copyright:

Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. Mathematica disclaims all liability for use or accuracy of any third-party codes contained in the specifications.

LOINC(R) copyright 2004-2024 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation. ICD-10 copyright 2024 World Health Organization. All Rights Reserved.

Disclaimer:

This performance measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Rationale:

Inpatient falls are among the most common incidents reported in hospitals and can increase length of stay and patient costs. Due to the potential for serious harm associated with patient falls, “patient death or serious injury associated with a fall while being cared for in a health care setting” is considered a Serious Reportable Event by the National Quality Forum (NQF).

Falls (including unplanned or unintended descents to the floor) can result in patient injury ranging from minor abrasion or bruising to death as a result of injuries sustained from a fall. While major injuries (e.g., fractures, closed head injuries, internal bleeding) (Mintz, 2022) have the biggest impact on patient outcomes, 2008-2021 data findings from The 2022 Network of Patient Safety Databases (NPSD) demonstrated that 41.8 % of falls resulted in moderate injuries such as skin tear, avulsion, hematoma, significant bruising, dislocations and lacerations requiring suturing. Moderate injury is, as defined by NDNQI, that resulted in suturing, application of steri-strips or skin glue, splinting, or muscle/joint strain (Press GaneyI, 2020). NPSD findings also demonstrated that mild to moderate level of harm represent 24.2.%, 0.4% - severe harm, and 0.1% - death (levels of harm definitions developed by WHO, 2009).

By focusing on falls with major and moderate injuries, the goal of this hospital harm eCQM is to raise awareness of fall rates and, ultimately, to improve patient safety by preventing falls with injury in all hospital patients. The purpose of measuring the rate of falls with major and moderate injury events is to improve hospitals’ practices for monitoring patients at high risk for falls with injury and, in so doing, to reduce the frequency of patient falls with injury.

Clinical recommendation statement:

Certain protocols and prevention measures to reduce patient falls with injury include using fall risk assessment tools to gauge individual patient risk, implementing fall prevention protocols directed at individual patient risk factors, and implementing environmental rounds to assess and correct environmental fall hazards. Recommended clinical guidelines and practices to reduce falls and injuries from falls in hospitals support many prevention activities including implementing multifactorial interventions and tailoring interventions to individual patient's conditions and needs. The intent and desired outcome for this eCQM is to work with existing and recommended falls prevention processes to track falls with injury, and aim to reduce rates of inpatient falls resulting in major injury.

Recommended falls prevention guidelines are:

Optimal Perioperative Management of the Geriatric Patient: Best Practices Guideline (ACS NSQIP/AGS, 2016)
Falls in older people: assessing risk and prevention (NICE, 2013)
Preventing falls and reducing injury from falls (4th edition) (RNAO, 2017)
Fall prevention in hospitals and nursing homes: Clinical practice guideline (Schoberer et al., 2022)
World guidelines for falls prevention and management for older adults: a global initiative, ('Montero-Odasso et al., 2022)

Guidance (Usage): Hospital days are measured in 24-hour periods starting from the time of arrival at the hospital (including time in the Emergency Department and or Observation). The number of days will be counted as whole numbers; any fractional periods are dropped. For example, an eligible encounter with a length of stay of 75 hours will be measured as 3 days (72 hours). This measure includes two measure observations used to calculate the ratio of the number of encounters with a fall over the total number of eligible hospital days. The ratio is reported as the rate of inpatient hospitalizations with falls with moderate or major injury per 1000 patient days. To express the rate of inpatient hospitalizations with falls with moderate or major injury per 1,000 patient days, the following calculation is applied post-production during implementation: (Total number of encounters with falls with moderate or major injury / Total number of eligible hospital days) x 1000 = rate. Example: 1 eligible encounter with a patient fall with moderate or major injury over 120 eligible days (1/120) x 1000 = 8.33. In ratio measures, both the Denominator and Numerator populations flow separately from the same Initial Population. Therefore, the same exclusion criteria must be applied to both the Denominator and Numerator to prevent excluded cases from being considered. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This FHIR-based measure has been derived from the QDM-based measure: CMS1017v2. Please refer to the HL7 QI-Core Implementation Guide (https://hl7.org/fhir/us/qicore/STU4.1.1/) for more information on QI-Core and mapping recommendations from QDM to QI-Core 4.1.1 (https://hl7.org/fhir/us/qicore/STU4.1.1/qdm-to-qicore.html).

Population Criteria:

6759fcdf46b6174510cfeffa

Initial Population:

Inpatient hospitalizations for patients aged 18 years and older with a length of stay less than or equal to 120 days that ends during the measurement period

Denominator:

Equals initial population

Denominator Exclusion:

Inpatient hospitalizations where the patient has a fall diagnosis present on admission.

Numerator:

Inpatient hospitalizations where the patient has a fall that results in moderate or major injury or death. The diagnosis of a fall and of a moderate or major injury must not be present on admission.

Numerator Exclusion:

Inpatient hospitalizations where the patient has a fall diagnosis present on admission

Measure Observation:

Denominator Observation, associated with the Denominator: The total number of eligible days across all encounters which match the initial population/denominator criteria.

Measure Observation:

Numerator Observation, associated with the Numerator: The total number of inpatient hospitalizations where a fall with major or moderate injury occurred, across all eligible encounters.

Libraries:

CMS1017HHFIFHIR

Terminology and Other Dependencies: Library/CQMCommon|2.2.000

Library/FHIRHelpers|4.4.000

Library/QICoreCommon|2.1.000

Encounter Inpatient

Observation Services

Emergency Department Visit

http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.171

http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.198

http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.174

http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.205

http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.197

Parameters:

name

use

min

max

type

Measurement Period

Period

Numerator

Out

Resource

Denominator

Out

Resource

Numerator Exclusions

Out

Resource

Initial Population

Out

Resource

Denominator Exclusions

Out

Resource

DataRequirements:

Resource Type

Resource Elements

Valueset Name

Valueset

Encounter(QICoreEncounter)

type status status.value period diagnosis

Observation Services

Encounter(QICoreEncounter)

type status status.value period diagnosis

Emergency Department Visit

Encounter(QICoreEncounter)

type status status.value period diagnosis

Encounter Inpatient

Encounter(QICoreEncounter)

type status status.value period diagnosis

Encounter Inpatient

Patient(QICorePatient)

Condition(QICoreCondition)

id id.value

AdverseEvent(QICoreAdverseEvent)

event date date.value recordedDate recordedDate.value

Inpatient Falls

http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.171

Logic Definitions:

Group Scoring Population Criteria Expression

6759fcdf46b6174510cfeffa Group scoring: ratio

Type:

Outcome

Rate Aggregation: None

Improvement Notation:

decrease

Initial Population

define "Initial Population":
  "Qualifying Encounter"

Denominator

define "Denominator":
  "Initial Population"

Denominator Exclusion

define "Denominator Exclusions":
  "Encounter with a Fall Present on Admission"

Numerator

define "Numerator":
  "Encounter where a Fall and Major Injury Occurred"
    union "Encounter where a Fall and Moderate Injury Occurred"

Numerator Exclusion

define "Numerator Exclusions":
  "Encounter with a Fall Present on Admission"

Measure Observation

define function "Denominator Observation"(QualifyingEncounter Encounter):
  duration in days of CQMCommon.HospitalizationWithObservation ( QualifyingEncounter )

Measure Observation

define function "Numerator Observation"(QualifyingEncounter Encounter):
  Count("Numerator" FallsEncounter
      where FallsEncounter.period ends during CQMCommon.HospitalizationWithObservation(QualifyingEncounter)
  )

Library Name Name

CQMCommon Inpatient Encounter

define "Inpatient Encounter":
  [Encounter: "Encounter Inpatient"] EncounterInpatient
		where EncounterInpatient.status = 'finished'
		and EncounterInpatient.period ends during day of "Measurement Period"

Library Name Name

CMS1017HHFIFHIR Qualifying Encounter

define "Qualifying Encounter":
  CQMCommon."Inpatient Encounter" InpatientEncounter
    //where InpatientEncounter.hospitalizationLengthOfStay() <= 120 
    
    where InpatientEncounter.hospitalizationWithObservation ( ).lengthInDays ( ) <= 120
      and AgeInYearsAt(date from start of InpatientEncounter.period) >= 18

Library Name Name

CMS1017HHFIFHIR Encounter with a Fall Not Present on Admission

define "Encounter with a Fall Not Present on Admission":
  "Qualifying Encounter" InpatientEncounter
    where exists ( InpatientEncounter.diagnosis Dx
        where CQMCommon."GetCondition" ( Dx.condition ).code in "Inpatient Falls"
              //and Dx.diagnosisPresentOnAdmission in "Not Present On Admission or Documentation Insufficient to Determine"
          
          and ( Dx.diagnosisPresentOnAdmission in "Not Present On Admission or Documentation Insufficient to Determine"
              or Dx.diagnosisPresentOnAdmission is null
          ) //new addition
    
    )

Library Name Name

CMS1017HHFIFHIR Encounter with a Fall Event

define "Encounter with a Fall Event":
  "Qualifying Encounter" InpatientEncounter
    with [AdverseEvent: event in "Inpatient Falls"] FallsDocumentation
      such that Coalesce(FallsDocumentation.date, FallsDocumentation.recordedDate) during CQMCommon."HospitalizationWithObservation" ( InpatientEncounter )

Library Name Name

CMS1017HHFIFHIR Encounter where a Fall Occurred

define "Encounter where a Fall Occurred":
  "Encounter with a Fall Not Present on Admission"
    union "Encounter with a Fall Event"

Library Name Name

CMS1017HHFIFHIR Encounter where a Fall and Major Injury Occurred

define "Encounter where a Fall and Major Injury Occurred":
  "Encounter where a Fall Occurred" FallOccurred
    where exists ( FallOccurred.diagnosis Dx
        where CQMCommon."GetCondition" ( Dx.condition ).code in "Major Injuries"
          and ( Dx.diagnosisPresentOnAdmission in "Not Present On Admission or Documentation Insufficient to Determine"
              or Dx.diagnosisPresentOnAdmission is null
          )
    )

Library Name Name

CMS1017HHFIFHIR Encounter where a Fall and Moderate Injury Occurred

define "Encounter where a Fall and Moderate Injury Occurred":
  "Encounter where a Fall Occurred" FallOccurred
    where exists ( FallOccurred.diagnosis Dx
        where CQMCommon."GetCondition" ( Dx.condition ).code in "Moderate Injuries"
          and ( Dx.diagnosisPresentOnAdmission in "Not Present On Admission or Documentation Insufficient to Determine"
              or Dx.diagnosisPresentOnAdmission is null
          )
    )

Library Name Name

CMS1017HHFIFHIR Numerator

define "Numerator":
  "Encounter where a Fall and Major Injury Occurred"
    union "Encounter where a Fall and Moderate Injury Occurred"

Library Name Name

CMS1017HHFIFHIR Initial Population

define "Initial Population":
  "Qualifying Encounter"

Library Name Name

CMS1017HHFIFHIR Denominator

define "Denominator":
  "Initial Population"

Library Name Name

CMS1017HHFIFHIR Encounter with a Fall Present on Admission

define "Encounter with a Fall Present on Admission":
  "Qualifying Encounter" InpatientEncounter
    where exists ( InpatientEncounter.diagnosis Dx
        where Dx.condition.getCondition ( ).code in "Inpatient Falls"
          and Dx.diagnosisPresentOnAdmission in "Present on Admission or Clinically Undetermined"
    )

Library Name Name

CMS1017HHFIFHIR Numerator Exclusions

define "Numerator Exclusions":
  "Encounter with a Fall Present on Admission"

Library Name Name

CMS1017HHFIFHIR Denominator Exclusions

define "Denominator Exclusions":
  "Encounter with a Fall Present on Admission"

Library Name Name

FHIRHelpers ToInterval

/*
@description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)
value to a CQL DateTime Interval
@comment: If the start value of the given period is unspecified, the starting
boundary of the resulting interval will be open (meaning the start of the interval
is unknown, as opposed to interpreted as the beginning of time).
*/
define function ToInterval(period FHIR.Period):
    if period is null then
        null
    else
        if period."start" is null then
            Interval(period."start".value, period."end".value]
        else
            Interval[period."start".value, period."end".value]

Library Name Name

CQMCommon lengthInDays

/*
@description: Calculates the difference in calendar days between the start and end of the given interval.
*/
define fluent function lengthInDays(Value Interval<DateTime> ):
  difference in days between start of Value and end of Value

Library Name Name

CQMCommon hospitalizationWithObservation

/*
@description: Hospitalization with Observation returns the total interval from the start of any immediately prior emergency department visit through the observation visit to the discharge of the given encounter
*/
define fluent function hospitalizationWithObservation(TheEncounter Encounter ):
  TheEncounter Visit
  		let ObsVisit: Last([Encounter: "Observation Services"] LastObs
  				where LastObs.status = 'finished'
            and LastObs.period ends 1 hour or less on or before start of Visit.period
  				sort by end of period
  			),
  			VisitStart: Coalesce(start of ObsVisit.period, start of Visit.period),
  			EDVisit: Last([Encounter: "Emergency Department Visit"] LastED
  				where LastED.status = 'finished'
            and LastED.period ends 1 hour or less on or before VisitStart
  				sort by end of period
  			)
  		return Interval[Coalesce(start of EDVisit.period, VisitStart), end of Visit.period]

Library Name Name

CQMCommon GetCondition

/*
@description: Returns the Condition resource for the given reference
@deprecated: This function is deprecated. Use the fluent function `getCondition()` instead
*/
define function "GetCondition"(reference Reference):
  singleton from ([Condition] C where C.id = reference.reference.getId())

Library Name Name

QICoreCommon getId

/*
@description: Returns the tail of the given uri (i.e. everything after the last slash in the URI).
@comment: This function can be used to determine the logical id of a given resource. It can be used in
a single-server environment to trace references. However, this function does not attempt to resolve
or distinguish the base of the given url, and so cannot be used safely in multi-server environments.
*/
define fluent function getId(uri String):
  Last(Split(uri, '/'))

Library Name Name

FHIRHelpers ToString

define function ToString(value uri): value.value

Library Name Name

CQMCommon HospitalizationWithObservation

/*
@description: Hospitalization with Observation returns the total interval from the start of any immediately prior emergency department visit through the observation visit to the discharge of the given encounter
@deprecated: This function is deprecated. Use the fluent function `hospitalizationWithObservation()` instead.
*/
define function "HospitalizationWithObservation"(TheEncounter Encounter ):
  TheEncounter Visit
  		let ObsVisit: Last([Encounter: "Observation Services"] LastObs
  				where LastObs.status = 'finished'
            and LastObs.period ends 1 hour or less on or before start of Visit.period
  				sort by end of period
  			),
  			VisitStart: Coalesce(start of ObsVisit.period, start of Visit.period),
  			EDVisit: Last([Encounter: "Emergency Department Visit"] LastED
  				where LastED.status = 'finished'
            and LastED.period ends 1 hour or less on or before VisitStart
  				sort by end of period
  			)
  		return Interval[Coalesce(start of EDVisit.period, VisitStart), end of Visit.period]

Library Name Name

CMS1017HHFIFHIR Denominator Observation

define function "Denominator Observation"(QualifyingEncounter Encounter):
  duration in days of CQMCommon.HospitalizationWithObservation ( QualifyingEncounter )

Library Name Name

CQMCommon getCondition

/*
@description: Returns the Condition resource for the given reference
*/
define fluent function getCondition(reference Reference):
  singleton from ([Condition] C where C.id = reference.reference.getId())

Library Name Name

CMS1017HHFIFHIR Numerator Observation

define function "Numerator Observation"(QualifyingEncounter Encounter):
  Count("Numerator" FallsEncounter
      where FallsEncounter.period ends during CQMCommon.HospitalizationWithObservation(QualifyingEncounter)
  )