This quarterly measure identifies the average percentage of healthcare personnel (HCP) who are considered up to date with recommended COVID-19 vaccines among the total number of HCP who regularly work in the facility.
The measure is reported for a quarter (3-month period). The quarterly COVID-19 vaccination coverage is determined by selecting one week per month and calculating the percentage of HCP who are considered up to date with recommended COVID-19 vaccines, then averaging 3 weekly percentages (one week from each of the 3 months in the quarter).
- Measure TypeElectronic Clinical Quality Measure (eCQM)Level Of AnalysisMAT output not attachedAttachedNumerator
The numerator for this measure consists of the cumulative number of HCP in the denominator population, who:
1. Are considered up to date with recommended COVID-19 vaccines administered at the healthcare facility; or
2. Are considered up to date with recommended COVID-19 vaccines administered elsewhere, based upon having reported in writing (paper or electronic) or provided documentation of being up to date with recommended COVID-19 vaccines.Up to date vaccination is defined by CDC Stay Up to Date with Your COVID-19 Vaccines | CDC and facilities are instructed to use the Up to Date definition as of the first day of the reporting quarter: https://www.cdc.gov/nhsn/pdfs/hps/covidvax/UpToDateGuidance-508.pdf
As of June 27, 2022 (the beginning of the three-month period tested), up to date included:
Persons aged <50 years who:
- Received at least one booster dose, OR
- Recently received all recommended doses in the primary vaccine series but are not yet eligible for a booster dose. This includes individuals who:- Completed their 2-dose primary vaccination series (Pfizer-BioNTech or Moderna vaccines) less than 5 months ago
- Received a single dose of Janssen less than 2 months agoPersons aged ≥50 years who:
- Received second booster dose (or received first booster dose less than 4 months ago and not yet eligible for a second booster dose), OR
- Recently received all recommended doses in the primary vaccine series but is not yet eligible for a booster dose. This includes individuals who:- Completed their 2-dose primary series of an mRNA COVID-19 vaccine (Pfizer-BioNTech or Moderna) less than 5 months ago
- Received a single dose of Janssen less than two months agoNotes:
A completed primary vaccine series was defined as receiving a 2-dose series of an mRNA COVID-19 vaccine (Pfizer-BioNTech and Moderna), OR a single dose of Janssen COVID-19 vaccine. (The Novavax COVID-19 Vaccine was approved by the FDA on July 13, 2022. The Novavax COVID-19 Vaccine, Adjuvanted is administered as a two-dose primary series. Individuals who completed the Novavax primary series were considered up to date two weeks after the final dose in their primary series, since a booster dose was not yet recommended for anyone who has completed the Novavax primary series.)
A booster dose is another dose of vaccine administered after receiving a primary vaccine series to enhance or restore protection which might have subsided over time.
Individuals are considered up to date with their COVID-19 vaccines when they have received all doses in the primary series and all booster doses recommended for them, when eligible.
DenominatorThe target population is the number of healthcare personnel (HCP) eligible to work in the healthcare facility for at least one day during the one-week data collection reporting period, excluding persons with contraindications/exclusions to COVID-19 vaccination. The quarterly reported measure includes at least one week of data collection a month for each of the 3 months in a quarter.
The denominators are reported to NHSN by the HCP categories below:
1. Employees: all persons who receive a direct paycheck from the reporting facility (i.e., on the facility's payroll).
2. Licensed independent practitioners: include physicians (MD, DO), advanced practice nurses, and physician assistants only who are affiliated with the reporting facility who do not receive a direct paycheck from the reporting facility.
3. Adult students/trainees and volunteers include all students/trainees and volunteers aged 18 or over who do not receive a direct paycheck from the reporting facility.
4. Other contract personnel: Facilities may also report on individuals who are contract personnel. However, reporting for this category is optional. Contract personnel are defined as persons providing care, treatment, or services at the facility through contract who do not fall into any of the above-mentioned denominator categories.ExclusionsExclusions include individuals with medical contraindications to COVID-19 vaccination.
All information required to stratify the measure resultsOffAll information required to stratify the measure resultsOffTesting Data Sources
- Measure StructureClinical Condition Topic AreaNon Condition SpecificTarget PopulationMeasure Selection AttributesNational Quality Strategy PrioritiesEffective Communication and Care Coordination
- Risk AdjustmentRisk adjustment approachOffRisk adjustment approachOffConceptual model for risk adjustmentOffConceptual model for risk adjustmentOff
- Current or planned use(s)Current Use(s)
- Most Recent Endorsement ActivityPatient Safety Spring 2023Initial EndorsementNext Planned Maintenance ReviewSpring 2028Endorsement StatusLast Updated
- Do you have a secondary measure developer point of contact?OffThe measure developer is NOT the same as measure stewardOffSteward Organization EmailSteward Organization Copyright
N/A
- Detailed Measure SpecificationsNoLogic ModelOffImpact and GapNoFeasibility assessment methodology and resultsNoAddress health equityNoMeasure’s use or intended useNo508 ComplianceOffIf no, attest that all information will be provided in other fields in the submission.Off
Effective March 27, 2023, the National Quality Forum (NQF) is no longer the consensus-based entity (CBE) funded through the Centers for Medicare & Medicaid Services (CMS) National Consensus Development and Strategic Planning for Health Care Quality Measurement Contract. Battelle has been selected to oversee the endorsement & maintenance (E&M) of clinical quality and cost/resource use measures. Since the Spring 2023 cycle launched at NQF, measures submitted to this E&M cycle continued along the prior E&M protocols that were in place at time of the Spring 2023 “Intent to Submit.” Battelle took over the E&M work for the Spring 2023 cycle when developers and/or stewards submitted their full measure information, which for CBE #3636, the most recent measure specifications can be found here: https://p4qm.org/sites/default/files/2023-06/3636_-_covid-19_vaccination_of_healthcare_personnel.zip
To close out this E&M cycle, Battelle published the Spring 2023 measures for pre-evaluation public commenting, convened the E&M standing committees for their measure evaluation meetings, launched the Spring 2023 post-comment period, convened the E&M committees for the post-comment meeting, convened the CSAC to render a final endorsement decision, and executed the appeals period.