Measure Set

The specific Joint Commission certification measure set to which a measure belongs (e.g., health care staffing services).

Measure ID #

A unique alpha-numeric identifier assigned to a measure. Information associated with a measure is identified by this unique alpha-numeric number.

Performance Measure Name

A brief title that uniquely identifies the measure.

Description

A brief explanation of the measure's focus, such as the activity or the area on which the measure centers attention (e.g., do not return, personnel file audit).

Rationale

An explanation that states why it is important to receive data/information on this measure. This may include specific literature references, evidence based information, expert consensus, etc.

Type of Measure

Indicates whether the measure is used to examine a process or an outcome over time.

• Process: A measure used to assess a goal directed, interrelated series of actions, events, mechanisms, or steps, such as measure of performance that describes what is done to, for, or by clinical employees of a healthcare staffing firm.
• Outcome: A measure that indicates the result of performance (or non-performance) of a function(s) or process(es).

Improvement Noted As

Describes how improvement would be indicated by the measure.

• An increase in the rate/score/number of occurrences (for example, personnel file audit)
• A decrease in the rate/score/number of occurrences (for example, staff turnover)
• Either an increase or a decrease in the rate/score/number of occurrences, depending upon the context of the measure (for example, utilization)

Numerator Statement

Represents the portion of the denominator population that satisfies the conditions of the performance measure to be an indicator event.

Included Population in Numerator Specific information describing the population(s) comprising the numerator, not contained in the numerator statement, or not applicable.

Excluded Population in Numerator Specific information describing the population(s) that should not be included in the numerator, or none.

Data Elements Those data elements necessary or required to determine (or establish) the numerator.

Denominator Statement

Represents the population evaluated by the performance measure.

Included Population in Denominator Specific information describing the population(s) comprising the denominator, not contained in the denominator statement or not applicable.

Excluded Population in Denominator Specific information describing the population(s) that should not be included in the denominator, or none.

Data Elements Those data elements required to determine (or establish) the denominator.

Data Collection Approach

Recommended timing for when data should be collected for a measure. Data collection approaches include retrospective, concurrent or prospective data collection. Retrospective data collection involves collecting data for events that have already occurred. Concurrent data collection requires the of gathering data while a process is occurring or in progress. Prospective data collection is data collection in anticipation of an event or occurrence.

Data Accuracy

Recommendations to reduce identifiable data errors, to the extent possible.

Measure Analysis Suggestions

Recommendations to assist in the process of interpreting data and drawing valid conclusions.

Sampling

Indicates whether a measure is amenable to selecting a random subset of a population in order to estimate the organization's performance level without collecting data for the entire population.

Data Reported As

Indicates how data will be reported for a measure.

• Aggregate rate generated from count data reported as a proportion (for example, rate-based measures which report summary data generated from the number of complete personnel files).
• Aggregate rate generated from count data reported as a ratio (e.g., medication errors per 1,000 patient days).
• Aggregate measures of central tendency (e.g., continuous variables which report the mean and median length of time such as the number of days to sell a property in a market area).

Calculation Model

A description of the steps or statistical calculations (computations) used to derive the numerator and denominator or continuous variable values required for a measure. Measure Information Forms in this manual will include either an algorithm or calculation model.

Selected References

Specific literature references that are used to support the importance of the performance measure.

Algorithm Introduction

Each measure is described by a unique algorithm. An algorithm is a predefined set of rules that help to break down complex processes into simple, repetitive steps.

Measure algorithms serve two purposes. First, they evaluate and identify missing and/or invalid data that will prohibit the ability to properly evaluate the measure. Second, they determine if:

• For rate-based measures, an item (e.g., personnel file) belongs in the measure population of interest described by the denominator, and if the event described in the numerator was present (e.g., background check).

This section contains some standard flow-charting conventions used to develop each algorithm:

• Flow lines are used to guide the reader to different parts of the algorithm, with arrows denoting the direction of movement. Generally, movement is from the top to the bottom of the chart.
• Symbols used in each algorithm flow charts are described later in this section under Flow Chart Symbols.
• Temporary variables within the algorithm are noted in the variable key at the top of each page.

Flowchart Symbols

Symbol	Explanation
	Start/Stop denotes the beginning or end of an algorithm
	Diamonds represent "If…Then" decision points for logic tests and comparisons. Two or three flow lines exit the decision point to reflect alternative actions based upon an evaluation of the condition(s) stated around the decision point.
	Rectangles or process boxes show when computation or manipulation of the data are required, such as a calculation or summarization.
	Circle or "On-page: connectors, labeled with a letter, show a link to sections of the algorithm which are continued on the same page.
	Five-sided or "Off-page" connectors, labeled with a letter, show a link to sections of the algorithm which are continued on different pages. Note: Both circular, On-page, five-sided, and Off-page Connectors containing the letters B, D, E, U, X, or Y lead to measure Outcome Boxes.
	Outcome Boxes represent the result of data passed through the algorithm. Connectors extending from outcome boxes lead to the end of the algorithm, or to risk adjustment procedures, where applicable. This symbol is also used to identify the strata within a stratified measure.
	Symbol to represent comments that should be taken into account when programming flowchart.
	This symbol is placed along side the Process box to which they are applicable. Comments are used to expand upon information contained within the process box, such as how to properly calculate age. Comments are never the sole location where processing logic is provided.
	Start/Return denotes the beginning and ending of a sub-routine. Algorithms that use this symbol are called from another algorithm and the data processing flow returns to the calling algorithm when the Return' is encountered. See the Initial Patient Population Algorithms and Transmission Data Processing Flows for an example of the usage of this symbol.

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