Introduction

This section of the manual describes the data elements required to calculate category assignments and measurements for The Joint Commission Health Care Staffing Services (HCSS) Measures. It includes information necessary for defining and formatting the data elements, as well as the allowable values for each data element. This information is intended to assist in processing data elements to calculate a measure rate.

It is of primary importance that all health care staffing firms using the HCSS measures gather and utilize the data elements as defined in this section.
Note: This will ensure that the data are standardized and comparable across organizations.

Data integrity

Editing Zero Values

Verification mechanisms are necessary to assure that zero is the intended data value rather than an initialization value for those data elements which have an allowable value of zero (i.e., 0.0, 0000, 0).

Missing and Invalid Data

Each data element that is applicable per the algorithm for each of the HCSS measures must be touched by the abstractor. While this is the expectation, it is recognized that in certain situations information may not be available (e.g., dates, times, etc.). After due diligence in reviewing all allowable data sources within the record, if the abstractor determines that a value is not documented, i.e. missing, or is unable to determine if a value is documented, the abstractor should select the UTD - Unable to Determine, value. The data elements Hire Date and Separation Date require an actual date to answer the data collection question. For Yes/No values the allowable value No incorporates the UTD into the definition. For data elements containing more than two categorical values and for numerical data elements (i.e., dates, times, etc.), a UTD option is included as an allowable value and is classified in the same category as not documented. For additional details on the proper handling of missing and/or invalid data, please refer to the Missing and Invalid Data section of this manual.

Interpreting Data Element Definitions and Allowable Values

Every attempt has been made to comprehensively define HCSS data elements and allowable values in a manner that obviates the need for interpretation. If, after reviewing the General Abstraction Guidelines, the data element definition, including the notes and guidelines for abstraction, an abstractor cannot clearly assign an allowable value, assistance may be requested via The Joint Commission Performance Measure Q&A Network at: .

Interpretation of Data Dictionary Terms

Data elements fall into three broad categories in order to support a specific measure set. They include:

• General Data Elements – data elements that must be collected for each HCSS measure
• Measure-Specific Data Elements – data elements used by one specific measure or several measures in one specific measure set, such as in the HCSS measures
• Algorithm Output Data Elements used to determine measure result

Data Element Dictionary Terms

Term	Definition
Data Element Name:	A short phrase identifying the data element. For identification, the data element name is italicized.
Collected For:	Identifies the measure(s) that utilize this data element or specifies that the data element is used for data processing or verification.
Definition:	A detailed explanation of the data element. Data collection software may include this information.
Suggested Data Collection Question:	Suggested wording for a data element question in a data abstraction tool.
Format:	Length = number of characters or digits allowed for the data element Type = type of information the data element contains (e.g., numeric, alphanumeric, date, character, or time) Occurs = the number of times the data element occurs in a single episode of care record
Allowable Values:	A list of acceptable responses for this data element
Notes for Abstraction:	Provided to assist the abstractor in the selection of an appropriate value for a data element
Suggested Data Sources:	Source document from which data can be identified such as the personnel file. Some data elements also list excluded data sources that are unacceptable sources for collecting information.
Guidelines for Abstraction:	Designed to assist abstractors in determining how a data element should be answered Note: Element specific notes and guidelines should take precedence over the General Abstraction Guidelines.

General Abstraction Guidelines

The abstractor should refer to the specific notes and guidelines under each data element. All of the allowable values for a given data element are outlined in its definition, and notes and guidelines for abstraction are included which provide the necessary direction for abstracting the data element. It is important to utilize the information found in the notes and guidelines when entering or selecting the most appropriate answer to the data collection question.

Record Documentation

The intent of abstraction is to use only documentation that was part of the record (e.g., personnel file) and present at the time of the original abstraction. It is not the intent to have documentation added at the time of abstraction to ensure the passing of a measure.

All documentation in the record must be legible, timed, dated and authenticated. However, documentation that is not timed, dated or authenticated may still be used for abstraction if not required by the specific data element. When abstracting a record, if a handwritten document is determined to be not legible, other documentation should be reviewed in an attempt to obtain the answer. If no other source document is able to verify the handwritten documentation, only then is the abstractor to answer unable to determine (UTD) from the record documentation, unless otherwise specified in the data element. Authentication may include written signatures, initials, computer key, or other codes.

Suggested Data Sources

• Suggested Data Sources are listed in alphabetical order, NOT priority order, unless otherwise specified in the data element.
• Suggested Data Sources are designed to provide guidance to the abstractor as to the locations/sources where the information needed to abstract a data element will likely be found. However, the abstractor is not limited to these sources for abstracting the information and must review the entire record unless otherwise specified in the data element.
• In some instances, a data element may restrict the sources that may be used to gain the information, list a priority in which the sources should be used or may restrict documentation by type of employee. If so, these sources will be identified and labeled as "Excluded Data Sources", "ONLY ACCEPTABLE SOURCES", or "Priority Source".
• If, after due diligence, the abstractor determines that a value is not documented or is not able to determine the answer value, the abstractor must select Unable to Determine (UTD) as the answer.
• Staffing firms may label forms and reports with unique names or titles. Suggested Data Sources are listed by commonly used titles; however, information may be abstracted from any source that is equivalent to those listed.
  • Example:
    If the personnel file is listed as a suggested source, an acceptable alternative might be title human resource file or employee file or human resource system/data base.

Inclusions/Exclusions

• Inclusions are acceptable terms as detailed in the data element definition that should be abstracted as positive findings (e.g., Yes).
• Inclusion lists are limited to those terms that are believed to be most commonly used in record documentation. The list of inclusions should not be considered all-inclusive, unless otherwise specified in the data element.
• Exclusions are unacceptable terms that should be abstracted as negative findings (e.g., No).
• Exclusion lists are limited to those terms an abstractor may most frequently question whether or not to abstract as a positive finding for a particular element (e.g., Do Not Use is an unacceptable term for Do Not Return and should be abstracted as "No"). The list of exclusions should not be considered all-inclusive, unless otherwise specified in the data element.
• When both an inclusion and exclusion are documented in a medical record, the inclusion takes precedence over the exclusion and would be abstracted as a positive finding (e.g., answer Yes), unless otherwise specified in the data element.

Grids

Instructions for reading values recorded on grids: Measure from the midpoint of the symbol, number and letter. If the value falls between two lines on the grid, abstract the earliest value.

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Alphabetical List of All Data Elements

Data Element Name	Collection Notes	Associated Measures
Assignment Type	All Records	HCSS
Background Check		HCSS-6, HCSS-7
Competency		HCSS-6, HCSS-7
Do Not Return		HCSS-4, HCSS-5
Exit Interview		HCSS-10, HCSS-11
Firm Group	All Records	HCSS
Hire Date		HCSS-8, HCSS-9
Job Appropriate Credentials		HCSS-6, HCSS-7
Measure Category Assignment	All Records, Calculation	HCSS
Placement Type	All Records	HCSS
Reason for Separation		HCSS-10, HCSS-11
Separation Date		HCSS-8, HCSS-9
Service Setting	All Records	HCSS
Voluntary Separation		HCSS-10, HCSS-11, HCSS-8, HCSS-9