Using The Specifications Manual for Joint Commission Health Care Staffing Services Measures

This portion of The Health Care Staffing Services (HCSS) Manual provides a brief overview of the information contained within each section of the manual. It is intended for use as a quick reference to assist in the implementation of the Joint Commission HCSS quality measures. The sections of this manual are interrelated and are most useful when considered together.

Measures listed in this manual are designed to be manually-abstracted measures. Manual abstraction is the review of documentation for the purposes of data collection and submission; however, electronic databases or record management systems/software may be used or adapted to assist with data collection.

Section 1: Measurement Information

The measure set sections contain specific measure information forms for each measure. This is followed by a data element list for the measures, including the general data elements, algorithm output data elements, and the measure-specific data elements. Next is a document that describes sample size requirements for the personnel file audit measures included in the HCSS measure set. Also included are subsections for each specific measure. These contain a Measure Information Form (MIF) and the Performance Measure Algorithm.

The algorithms and data elements needed to calculate each of the HCSS measures are identified in the MIF. Each algorithm provides the logical steps, data element evaluation, arithmetic calculations, and data manipulation steps that are required to calculate a given measure.

Section 2: Data Dictionary

The Data Dictionary describes the data elements required to capture and calculate individual measure rates. It specifies those general data elements that must be collected for all HCSS measures and the data elements needed for a specific measure.

Section 3: Overview of Measure Information Form and Flowchart Formats

The Overview of Measure Information Form and Flowchart Formats explains each of the terms used on the Measure Information Form and provides a brief introduction to flowcharting, including an explanation of flowchart symbols. Each measure has an associated Measure Information Form and Flowchart (calculation algorithm).