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Specifications Manual for Joint Commission National Quality Measures (v2015A1)
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Release Notes:
Using The Manual TJC
Version 2015A1

Using The Specifications Manual for Joint Commission National Quality Core Measures

This portion of The Specifications 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 national quality core measures. The sections of this manual are interrelated and are most useful when considered together.

This manual contains references to CMS and QIO programs that, while not applicable to the Joint Commission, have been retained to remain consistent with the CMS and Joint Commission aligned Specifications Manual for National Hospital Inpatient Quality Measures.

Section 1: Data Dictionary

The Data Dictionary describes the patient-level and facility-level data elements required to capture and calculate individual measurements. It specifies those data elements that must be collected for each patient that falls into the selected measure population and the data elements needed for a specific measure.

Section 2 - 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 specific measure data elements. Next is a document that describes the initial patient population and sample size requirements for each 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 Joint Commission national quality core 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 3: Missing and Invalid Data

This section addresses the Joint Commission’s approach to missing and invalid data. Missing data refers to data elements that have no values present for one or more episodes of care and invalid data refers to data element values that fall outside the range of the allowable values. Information and examples are provided on how the “Unable to Determine” (UTD) value is utilized within the measure algorithm and on submission into the Joint Commission’s Data Warehouse. This section also describes the general and measure specific data elements that are required for submission and how missing and/or invalid data will be handled.

Section 4: Population and Sampling Methods

Sampling is an available option for all Joint Commission national quality core measures if certain requirements are met. This section provides guidance on defining the hospital’s Initial Patient Population and information and examples on the order of data flow, sample size requirements, sampling approaches and the transmission of Initial Patient Population and sample data elements to the Joint Commission’s Data Warehouse. Specific measure set sample size requirements tables are located in the Measure Information section.

Section 5 – Joint Commission National Quality Core Measure Verification Process

This section has been moved to the ORYX Technical Implementation Guide and is available to ORYX Vendors via the Joint Commission’s extranet site for measurement systems (PET).

Section 6 – Joint Commission National Quality Core Measures Data Transmission

This section of the manual is provided to highlight the unique data transmission specifications for Joint Commission national quality core measure data. This section is divided into four parts: Joint Commission National Quality Core Measure Data Transmission, Guidelines for Submission of Data, Transmission Data Element List, and Transmission Data Processing Flow.

The Joint Commission Data Transmission section provides information related to the transmission of Joint Commission 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 Data Element List 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 contains information regarding the order in which the Joint Commission’s Data Warehouse evaluates the Joint Commission national quality core measures and the population and sampling data.

Appendix A - ICD-9-CM Code Tables

For many of the measures, eligibility for inclusion or exclusion in the Initial Patient Population of interest is defined by the presence of certain ICD-9-CM diagnosis and procedure codes within the patient-level record. Appendix A contains the ICD-9-CM code tables that define these indicator populations for all measures within each measure set. There is a description of the code as defined in a coding manual and a shortened description that may be used in a data abstraction tool. The Measure Information Section also refers to the codes or tables provided in this section. ICD-9-CM codes are modified by the National Center for Health Statistics (NCHS) and the Centers for Medicare & Medicaid Services (CMS). The code tables in this Appendix are evaluated semiannually and modified based on these changes. Potential changes become effective beginning with either April 1st or October 1st discharges. Updates will be provided as indicated.

Appendix C –- Medication Tables

Some of the Joint Commission national quality core measures address the use of certain medications. This Appendix contains tables with the specific names of medications that may be associated with medication categories (e.g., trade names). For example, Haloperidol may also be documented as Haldol. These tables are provided to facilitate appropriate data collection of applicable medications. These tables are not meant to be an inclusive list of all available therapeutic agents; rather they represent current information available at the time of publication. Approved medication tables will be updated regularly. Discrepancies must be reported. See the Resource Section of this manual for contact information.

Appendix D -– Glossary of General Terms

Appendix E -– Overview of Measure Information Form and Flowchart Formats

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

Appendix G - Resources

This section lists resources that are available to assist with the Joint Commission measures.

Appendix H -– Miscellaneous Tables

The tables in this Appendix contain clinical information to supplement the data element dictionary and provide additional details for data abstraction. They are referenced under the data dictionary under the Notes for Abstraction or the Guidelines for Abstraction.

Appendix P -– Preview Section

The preview section is intended to provide an overview of future updates. The information provided in this section is not to be programmed or submitted. Placement in this appendix does not assume that the information listed will be implemented in a future manual.

Related Topics

Related Topics

Using The Manual TJC
Specifications Manual for Joint Commission National Quality Measures (v2015A1)
01/01/2015 - 09/30/2015