Performance Measurement Network

Question: What number should we enter for the denominator?

For HCSS-6 Completeness of the Personnel File, if we audit 20 files and 19 are compliant, do we report 20 files or 362 total number of clinical employees as the denominator?

Numerator 19, Denominator 20 OR Numerator 19, Denominator 362?

Answer:

The denominator would not be 362. This is the total number of clinical placements you had over a 12 month period. This number is used to identify your firm group and what sub-measure to report - 6a, 6b, 6c, or 6d. It is also used to identify the minimum number of files to be sampled each month. Please see the Sampling Section of the specifications manual for more information about the sampling methodology.

HCSS-6 denominator is: Per diem clinical placements for the reporting month. This may be a different number of employees each month. Slight variation in the number of employees each month should not change your firm group or the minimum number of files needed each month if sampling.

If your total number of clinical placements is >/= 350, then the minimum sampling requirement is 20, i.e., 20 clinical employees = 20 personnel files. Each employee should have a personnel file.

Twenty is the highest denominator that is possible for HCSS-6 and HCSS-7 Completeness of the Personnel File based on the sampling methodology in the manual. Your firm would enter Numerator 19 and Denominator 20, if 19 of the 20 personnel files auditted were compliant and met the measure criteria for background check, job appropriate credentials, and clinical competency.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: HCSS-6,

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