Introduction

This section of the manual is provided to highlight the unique data transmission specifications for The Joint Commission national quality core measure data.

This section is divided into four parts: National Quality Core Measure Data Transmission, Guidelines for Submission of Data, Transmission Alphabetical Data Dictionary, and Transmission Data Processing Flows.

The Data Transmission section provides information related to the transmission of national quality core measure data to the Joint Commission’s Data Warehouse.

The Guidelines for Submission of Data includes an overview of the data required to be submitted to the Joint Commission’s Data Warehouse, as well as the Hospital Clinical Data XML file layout and the Hospital Initial Patient Population Data XML file Layout.

The Transmission Alphabetical Data Dictionary describes the data elements that are either used to identify the hospital and measure set associated to the transmitted data or are calculated by the vendor using the hospital’s patient-level data and measure results. These data elements are not used in the Initial Patient Population Algorithms or Measure Algorithms.

The Transmission Data Processing Flows contain information regarding the order in which the Joint Commission’s Data Warehouse evaluates the national hospital quality measures and the associated population and sampling data. In addition, it highlights the decision points as to when cases are rejected from the warehouse. Refer to the Edit Message documents located on the Upload/Download page in the HCD section of PET for The Joint Commission for a complete listing of all critical and informational edits.

The Joint Commission National Quality Core Measure Data Transmission

Overview

The Joint Commission requires three different data transmissions related to the national quality core measure data. All of these transmissions are submitted by ORYX® Vendors and follow the same data transmission schedule used to submit ORYX data to The Joint Commission. The most significant items related to the transmission of national quality core measure data are listed here, but this is not an exhaustive list. Refer to the appropriate documents as detailed below for more information.

Download File Layouts

• Download Hospital Clinical Data XML File Layout (MS Excel)

• Download ICD Population XML File Layout (MS Excel)

Hospital Initial Patient Population Data

The Joint Commission collects Initial Patient Population and sampling information by Measure Set. This data is required to be submitted to The Joint Commission on a quarterly basis. All Initial Patient Population and sampling data will be submitted in an XML file that adheres to the Hospital Initial Patient Population Data XML File Layout specifications and guidelines provided later in this section. Each file may contain data for only one provider.

Hospital Clinical Data

Hospital clinical data is required to be submitted to The Joint Commission no less than on a quarterly basis. All HBIPS and PC patient-level data submitted to The Joint Commission must adhere to the Hospital Clinical Data XML File Layout specifications and guidelines provided later in this section. The hospital clinical data submitted to The Joint Commission is anonymous because no direct patient identifiers are included in the Hospital Clinical Data XML File.

If a patient has also been sampled for a different national hospital quality measure set, then a separate XML file must be created for the additional measure set. Refer to the applicable version of the Specifications Manual for National Hospital Inpatient Quality Measures for information on how to create and transmit the data for the other measure set.

Each HBIPS discharge case and event case must have a separate XML file. For example:
Example #1: During the quarter, 10 patients are discharged (Discharge Date) and no restraint or seclusion events occurred for any patient (not just those discharged). Ten (10) separate XML files are created and transmitted, one for each discharged patient.

Example #2: During the quarter, no patients are discharged (Discharge Date) and 4 unique patients have restraint or seclusion events for a total of 11 events. Eleven (11) separate XML files are created and transmitted, one for each event (Event Date). Multiple events (Event Date) for a patient cannot be combined into one XML file. If the same patient is restrained and seclude (Event Type) on the same day (Event Date), the two events must be transmitted in separate XML files.

Example #3: During the quarter, 1 patient is discharged (Discharge Date) and 1 unique patient has a restraint event and a seclusion event (Event Date) for a total of 2 events. The patient with the events is the same patient that was discharged. Three (3) separate XML files are created and transmitted, one for the patient’s discharge information (Discharge Date) and one for each event (Event Date and Event Type). A patient’s discharge information and event information cannot be combined into the same XML file.

Additional information:

For more information concerning the Performance Measurement System Identifier, refer to the ORYX Technical Implementation Guide . For more information concerning the Vendor Tracking ID and Health Care Organization Identifier, refer to the Transmission Alpha Data Dictionary in this manual.

• Unique Key Identifier for Discharge Measures (e.g., HBIPS-1, HBIPS-4, PC-01):
  • Performance Measurement System Identifier – not part of the file, captured at the point the file is uploaded to The Joint Commission
  • Vendor Tracking ID – fictitious identifier generated by the measurement system to differentiate between individual patient records from each hospital
  • Admission Date
  • Discharge Date
  • Measure Set
  • Health Care Organization Identifier

• Unique Key Identifier for Event Measures (e.g., HBIPS-2 and HBIPS-3):
  • Performance Measurement System Identifier – not part of the file, captured at the point the file is uploaded to The Joint Commission
  • Vendor Tracking ID – fictitious identifier generated by the ORYX Vendor to differentiate between individual patient records from each hospital
  • Admission Date
  • Event Date
  • Event Type
  • Measure Set
  • Health Care Organization Identifier

• Transaction Processing: Data can be added, replaced, and deleted during the current reporting quarter using the Action-Code in the XML file. In order to replace or delete an existing file at The Joint Commission, the files must match on the unique key data elements as defined above. In order to update a key element in an existing file, the file must be deleted and a new file must be submitted. If the element to update is not a key element, then the file can be resubmitted using the ‘Add’ Action-Code; there is no need to delete the file first as long as the file matches on the unique key data elements.

• Measure Selection: Data that passes all edits and contains all data required to calculate the measures will be accepted as long as the hospital (identified by the Health Care Organization Identifier) has selected the measure set for the reporting quarter with the ORYX Vendor that is submitting the data.

• Sample: All EOC and event records included in the sample, or if the hospital is not sampling the Initial Patient Population, must be transmitted to The Joint Commission. This is true regardless of whether or not any measure for the record calculates to a Measure Category Assignment = “X”. Note – the HBIPS event measures (HBIPS-2 and 3) do not allow sampling, all data in the Initial Patient Population of these two measures must be transmitted.

• Data Elements Not Accepted by The Joint Commission: The following data elements may be transmitted to the Centers for Medicare and Medicaid Services (CMS) for the aligned national hospital quality measures but cannot be transmitted to The Joint Commission for any measure because the data transmitted to The Joint Commission are anonymous. For information concerning these data elements, refer to the applicable version of the Specifications Manual for National Hospital Inpatient Quality Measures. Files transmitted to The Joint Commission that contain the following data will be rejected:
  • Patient Identifier
  • Patient HIC #
  • First Name
  • Last Name
  • Postal Code

• Data Elements Required by The Joint Commission: In order to support the Joint Commission’s data quality analysis and continuous measure verification process the following data elements are required to be transmitted for each measure in the HBIPS measure set.
  • Measure Category Assignment
  • Measurement Value
  • Predicted Value

• A fictitious identifier is generated by the ORYX Vendor to differentiate between individual patient records from each hospital because the Joint Commission’s data are blinded as to whom the patient is. The following data element is used to transmit this fictitious identifier.
  • Vendor Tracking ID
    This identifier is unique to a patient.

• For each patient episode of care the following patient identifiers should match for each Measure Set that is submitted for Discharge Measures (e.g., HBIPS-1, HBIPS-4, PC-01).
  • Vendor Tracking ID
  • Admission Date
  • Discharge Date
  • Birthdate
  • Health Care Organization Identifier
    For example, if the hospital submits a separate XML file for AMI, PC, HBIPS, and TOB, the above identifiers should be the same in each of the discharge XML files.

• For HBIPS records, if the patient has multiple events(e.g., HBIPS-2 and HBIPS-3), the following patient identifiers should match for each event record transmitted.
  • Vendor Tracking ID
  • Admission Date
  • Birthdate
  • Health Care Organization Identifier
    In addition, the discharge record must also be transmitted with the same identifiers.

• HBIPS Specific Data Elements Not Accepted by The Joint Commission As Part of HCD: The following data elements will not be transmitted to The Joint Commission in the Hospital Clinical Data (HCD) file. These data are aggregated at the hospital level and are not patient specific data. Performance measurement systems will reference the applicable version of the ORYX Technical Implementation Guide for instructions on how to use the data elements to calculate the HCO-level aggregate data (see below). Files transmitted to The Joint Commission that contain the following data will be rejected:
  • Psychiatric Inpatient Days - Medicare Only
  • Psychiatric Inpatient Days - Non-Medicare Only
  • Total Leave Days - Medicare Only
  • Total Leave Days - Non-Medicare Only

Aggregate Data

Aggregate hospital data is required to be submitted to The Joint Commission no less than on a quarterly basis.

• Include in the HCO-level statistical aggregate data (e.g., Observed Rate and Number of Cases) only those cases which process through the patient-level edits without being rejected and do not receive a Measure Category Assignment = X for any measure in the set. Refer to the “HCO-Level Data Elements” and “Electronic Data Interchange” sections of the ORYX Technical Implementation Guide for a complete set of definitions, allowable values, and edits related to the data elements “Observed Rate”, “Number of Cases”, and “Number of Rejected Cases”. In addition, refer to the data element “Number of Rejected Cases” for information on how to report the number of cases excluded from the HCO-level statistical aggregate data due to data quality and missing data issues.

• Technical Manual: ORYX Vendors will reference the applicable version of the ORYX Technical Implementation Guide for instructions and data element definitions that pertain to the transmission of aggregate data for national hospital quality core measure data, including how to calculate the HCO-level aggregate data.

• Stratified national quality core measures and Sub-Measures: Although a stratified measure or sub-measures will often be referred to as a single measure (such as measure HBIPS-1), the overall rate, sub-measures, and the individual strata measures and will actually be transmitted to The Joint Commission in the aggregate HCO-level data as a series of measures, using a number of pre-determined transmission ID numbers.

• Missing and Invalid Data: The following data elements are required for national hospital quality measures and must be included in the health care organization (HCO)-level data transmission file. These will not be used for traditional ORYX data. The data elements include:
  • Number of Rejected Cases
  • Number of Cases with UTD Allowable Values
  • ICD Population Size
  • Sample
    Refer to the “HCO-Level Data Elements” and “Electronic Data Interchange” sections of the ORYX Technical Implementation Guide for a complete set of definitions, allowable values, and edits related to these data elements.
    

• Five or fewer cases: The following HCO-level aggregate data elements are still required for hospital electronic to not report data for the quarter because they have five or fewer discharges (both Medicare and non-Medicare combined) for the set. The data elements include:
  • ICD Population Size
  • Sample
  • Data Received for Health Care Organization
    Note: Hospitals may choose to not report data when they have five or fewer discharges for Discharge measures only (e.g., HBIPS-1, 4, PC-01). Hospitals must report all data for Event measures regardless of the number of discharges or events that occur during the quarter. Refer to the “HCO-Level Data Elements” and “Electronic Data Interchange” sections of the ORYX Technical Implementation Guide for a complete set of definitions, allowable values, and edits related to these data elements.
    

• Identifiers used to transmit national quality core measure data: The performance measure identifiers used to transmit aggregate HCO-level data to The Joint Commission are maintained within the ORYX Technical Implementation Guide. ORYX Vendors have access to the ORYX Technical Implementation Guide through the Performance Measurement System Extranet Track (PET).

• ORYX data re-transmission: The Joint Commission acknowledges that it is appropriate to allow ORYX data to be updated. We are interested in assuring the best possible data quality, especially in light of public reporting. With each regularly scheduled transmission deadline, we routinely accept retransmission of up to seven quarters of aggregate national quality core measures. In addition, we accept retransmission of up to seven quarters of aggregate non-core measure data. The purposes of the accepting the retransmitted data is to update the data for the ORYX Performance Measure Reports, national comparison group data, and the health care organization Quality Report postings. These retransmitted data may be inclusive of updated data previously submitted and/or data that may have been erroneously omitted.
  
  ORYX Vendors are required to correct their recognized data integrity issues and retransmit up to seven quarters of updated aggregate national quality core measures and aggregate non-core measure data (due to the rolling quarters of the ORYX Performance Measure Reports that display up to 24 months of data) by the next regularly scheduled quarterly transmission deadline. Retransmission of corrected aggregate data from issues emanating at the client health care organization-level is encouraged whenever feasible. It is the responsibility of the ORYX Vendor to notify their clients that updated data were retransmitted to The Joint Commission, and that the subsequent Quality Report posting and future ORYX Performance Measure Reports will reflect these data. It is important to note, these retransmitted data will refresh the following quarter’s ORYX Performance Measure Reports and Quality Report (core only), and update the national comparison group rates (core only).
  
  Refer to the ORYX Performance Measurement System Agreement, ORYX Data Retransmission Process, for further details and associated fees that apply. ORYX Vendor inquires related to the retransmission of ORYX data should be directed to http://manual.jointcommission.org.

Information The Joint Commission Provides To Core ORYX Vendors

Risk Adjustment: The Joint Commission will provide ORYX Vendors with risk adjustment model information for the active national quality core measures (e.g., PC) that require risk adjustment. ORYX Vendors must apply the risk model information to their patient-level data and generate aggregate risk adjustment data for submission to The Joint Commission as a part of HCO-level data elements. Additional specifics include:

• ORYX Vendors will have access to current national quality core measure risk model information files through the Performance Measurement System Extranet Track (PET).
• Details related to the risk model information file, its usage by ORYX Vendors and a list of significant risk factors are provided in the ORYX Risk Adjustment Guide. This guide is available to the public on the Joint Commission’s website and, in addition, it is available to ORYX Vendors via the Joint Commission’s extranet site for ORYX Vendors (PET).
• National quality core measure risk models must not be used for any purposes other than calculating risk-adjusted data elements.
• For assistance with the national quality core measure risk model information, please contact the ORYX statistical support staff at http://manual.jointcommission.org and click on Statistical Support.

National Comparison Group: The Joint Commission will provide ORYX Vendors participating in the ORYX national quality core measure initiative with national comparison group data. ORYX Vendors may use this information to prepare feedback reports for client organizations. Additional details in regard to this process include:

• ORYX Vendors will have access to national comparison group data through the Performance Measurement System Extranet Track (PET).
• Refer to the ORYX Data Quality Manual for the list of national comparison group data elements, how ORYX Vendors may utilize this data, and related information.
• For assistance with the national quality core measure national comparison group, please contact the ORYX statistical support staff at http://manual.jointcommission.org and click on Statistical Support.

Joint Commission Guidelines for Submission of Data

Overview

The below guidelines are for the submission of Hospital Clinical Data and Hospital Initial Patient Population Data to The Joint Commission. Additionally, for the Joint Commission’s Hospital Clinical Data Edit and Algorithm Error Feedback Messages, please refer to the Joint Commission’s extranet for measurement systems (PET).

• Error Messages provide feedback regarding submitted data, file structure and data integrity that either cause the case to be rejected from the warehouse (Critical) or ask for further verification (Informational). Cases with any critical error messages will not be processed or stored in the warehouse. For cases to be accepted into the warehouse all critical errors must be corrected and the case resubmitted. Informational errors are feedback that warn of potential issues and ask for verification. Cases that receive no error messages or that receive informational messages only will be processed as per the measure algorithm.
• Missing Messages are critical edits that will cause the case to be rejected from the warehouse due to missing data, as per the measure algorithms, resulting in a measure outcome of “X” (Data are Missing).
• Measure Messages provide feedback related to the outcome of the case, as per the measure algorithm, resulting in any other measure outcome, i.e., “B” (Not in Measure Population/Excluded), “D” (In Measure Population/Failed), “E” (In Numerator Population/Passed), or “Y” (Unable to Determine Allowable Value Does Not Allow Calculation of the Measure/UTD).

Abstraction Software Skip Logic and Missing Data

Skip logic allows hospitals and vendors to minimize abstraction burden by using vendor software edit logic to bypass abstraction of data elements not utilized in the measure algorithm. However, these bypassed elements also negatively impact data quality when elements are incorrectly abstracted and subsequent data elements are bypassed and left blank.

The use of skip logic by hospitals and ORYX vendors is optional and not required by The Joint Commission. Hospitals should be aware the potential impact of skip logic on data quality and abstraction burden. Vendors and hospitals utilizing skip logic should closely monitor the accuracy rate of abstracted data elements, particularly data elements placed higher in the algorithm flow.

Joint Commission Guidelines for Submission of Hospital Initial Patient Population Data

Hospitals must submit to The Joint Commission on a quarterly basis the aggregate population and sample counts for Medicare and non-Medicare discharges for each of the measure sets. If the aggregate population count is zero, the hospital is still required to submit the Hospital Initial Inpatient Population Data file and would submit zero as the population and sample counts. In addition, The Hospital Initial Inpatient Population Data file must be transmitted to the Joint Commission's Data Warehouse even if the hospital has elected to not report the patient data for the Discharge measures (e.g., HBIPS1, 4, PC-01) when they have five or fewer cases for an appropriate measure set during the quarter.