Using The Specifications Manual for Joint Commission National Quality 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 measures. The sections of this manual are interrelated and are most useful when considered together.

Measures listed in this manual are Chart-Abstracted Measures. Chart abstraction is the review of medical record documentation from the current episode of care for the purposes of data collection and submission.

In addition, some of the measures in this manual have been retooled as eMeasures and are eligible for voluntary electronic submission for ORYX performance measure reporting requirements or the Hospital Inpatient Quality Reporting (IQR) program). For information about the requirements and technical specifications of the Quality Reporting Document Architecture (QRDA) specifications and data submission, see the resources located on QualityNet, [Hospitals-Inpatient], Electronically Specified Clinical Quality Measures (eCQM) Reporting. The Joint Commission ORYX performance measure reporting requirements are available on the Joint Commission website under the Measurement tab and on Performance Measurement System Extranet track site (PET) under Manuals and Guides, eCQM Documentation.

Selected standardized measure sets used in the Joint Commission Certification programs have been incorporated in this specification manual. This is being done to centralize the measures used for Joint Commission programs into one manual. Note: the Stroke (STK) measures data for certification can be submitted through an ORYX vendor, however the Advanced Certification Heart Failure (ACHF) measures data cannot be submitted through an ORYX vendor and may only be submitted through the Certification Measure Information Process (CMIP).

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 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 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 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 Measures Data Transmission

This section of the manual is provided to highlight the unique data transmission specifications for Joint Commission national quality measure data. This section is divided into four parts: Joint Commission National Quality 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 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 measures and the population and sampling data.

Appendix A - ICD-10 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-10-CM diagnosis and ICD-10-PCS procedure codes within the patient-level record. Appendix A contains the ICD-10 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-10 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 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.

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