Specifications Manual for Joint Commission National Quality Measures (v2018A1)
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Release Notes:
Measure Information Form
Version 2018A1


Advanced Certification Heart Failure Outpatient (ACHFOP)

Set Measures

Set Measure ID Measure Short Name
ACHFOP-01 Hospital Outpatient Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate Prescribed for LVSD)
ACHFOP-02 Hospital Outpatient ACEI or ARB Prescribed for LVSD
ACHFOP-03 Hospital Outpatient Aldosterone Receptor Antagonists Prescribed for LVSD
ACHFOP-04 Hosptial Outpatient New York Heart Association (NYHA Classification Assessment)
ACHFOP-05 Hospital Outpatient Activity Recommendations
ACHFOP-06 Hospital Outpatient Discussion of Advance Directives/Advance Care Planning
ACHFOP-07 Hospital Outpatient Advance Directive Executed

General Data Elements

Element Name Collected For
Birthdate All Records,
ICD-10-CM Principal Diagnosis Code All Records, Optional for HBIPS-2, HBIPS-3
ICD-10-PCS Other Procedure Codes All Records, Optional for All HBIPS Records
ICD-10-PCS Principal Procedure Code All Records, Optional for All HBIPS Records
ICD-10-PCS Principal Procedure Date All Records, Optional for All HBIPS Records

Measure Set Specific Data Elements

Element Name Collected For
ACEI Prescribed for LVSD in the Outpatient Setting ACHFOP-02,
ARB Prescribed for LVSD in the Outpatient Setting ACHFOP-02,
Activity Recommendation — Duration of Activity ACHFOP-05,
Activity Recommendation — Intensity of Activity ACHFOP-05,
Activity Recommendation — Type of Activity ACHFOP-05,
Advance Directive Executed ACHFOP-07,
Aldosterone Receptor Antagonist Prescribed for LVSD in the Outpatient Setting ACHFOP-03,
Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD in the Outpatient Setting ACHFOP-01,
Clinical Trial ACHFOP-01, ACHFOP-02, ACHFOP-03, ACHFOP-04, ACHFOP-05,
Discharge Code ACHFOP,
Discussion of Advance Directives/Advance Care Planning ACHFOP-06,
E/M Code ACHFOP,
LVSD < 40% ACHFOP-01, ACHFOP-02, ACHFOP-03,
New York Heart Association (NYHA) Classification ACHFOP-04,
Outpatient Encounter Date ACHFOP,
Reason for No ACEI and No ARB Prescribed for LVSD in Outpatient Setting ACHFOP-02,
Reason for No Activity Recommendations in the Outpatient Setting ACHFOP-05,
Reason for No Aldosterone Receptor Antagonist Prescribed for LVSD in the Outpatient Setting ACHFOP-03,
Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD in the Outpatient Setting ACHFOP-01,


  Document Name  
Acknowledgment and Conditions of Use  
Appendix A - ICD-10 Code Tables  
Appendix C - Medication Tables  
Appendix D - Glossary of Terms  
Appendix E - Overview of Measure Information Form and Flowchart Formats  
Appendix G - Resources  
Appendix H - Miscellaneous Tables  
Data Dictionary  
Cover Page for the Joint Commission Manual  
Introduction to the Manual  
Missing and Invalid Data  
Sampling  
Table of Contents  
Transmission Alpha Data Dictionary  
Transmission Data Processing Flow: Clinical  
Transmission Data Processing Flow: Population and Sampling  
Transmission of Data  
Using the The Joint Commission's National Measure Specifications Manual  

Initial Patient Population

ACHFOP_Init_Pop.jpg

HF Sample Size Requirements

Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may choose to use a larger sample size than is required. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. Hospitals that have five or fewer HF discharges (both Medicare and non-Medicare combined) in a quarter are not required to submit HF patient level data to the QIO Clinical Warehouse1 and Joint Commission's Data Warehouse.

Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size.

The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual.

Quarterly Sampling

Hospitals performing quarterly sampling for HF must ensure that its Initial Patient Population and sample size meet the following conditions:

Quarterly Sample Size
Based on Initial Patient Population Size for the HF Measure Set

Hospital's Measure
Average Quarterly
Initial Patient Population
Size “N”
Minimum Required
Sample Size
“n”
≥ 1516 304
381 — 1515 20% of Initial Patient Population size
76 — 380 76
6 — 75 No sampling; 100% Initial Patient Population required
0 - 5 Submission of patient level data is encouraged but
not required:
  • CMS: if submission occurs, 1-5 cases
    of Initial Patient Population may be submitted1
  • The Joint Commission: if submission
    occurs, 100% Initial Patient Population required

Monthly Sampling

Hospitals performing monthly sampling for HF must ensure that its Initial Patient Population and sample size meet the following conditions:

Monthly Sample Size
Based on Initial Patient Population Size for the HF Measure Set

Hospital's Measure
Average Monthly
Initial Patient Population
Size “N”
Minimum Required
Sample Size
“n”
≥ 506 102
131 — 505 20% of Initial Patient Population size
26 — 130 26
<26 No sampling; 100% Initial Patient Population required

Sample Size Examples

  • Quarterly sampling:
    • The HF Initial Patient Population size for a hospital has been 500 patients per quarter during the past year. The required quarterly sample size would be 100 (twenty percent of 500) heart failure patients per quarter -- as this number is smaller than the maximum condition (i.e., 304 cases) and larger than the minimum condition (i.e., 76 cases).
    • A hospital's HF Initial Patient Population size is 1,482 patients during the third quarter. The required sample size is 20% of the patient population or 297 cases for the quarter (twenty percent of 1,482 equals 296.4 rounded to the next highest whole number equals 297).
    • A hospital's HF Initial Patient Population size is 5 patients during the first quarter. Submission of patient level data is not required. If the hospital chooses to submit patient level data:
      • CMS: the quarterly sample size would be 1 — 5 cases for the quarter.1
      • The Joint Commission: the required quarterly sample size would be 100% of the patient population or 5 cases for the quarter.

  • Monthly sampling:
    • A hospital's HF Initial Patient Population size is 25 patients during March. Since this is less than the minimum condition (i.e., 26 cases), no sampling is allowed or 100% of the patient population of 25 cases is required.
    • A hospital's HF Initial Patient Population size is 503 patients during July. The required sample size is 20% of the patient population or 101 cases for the month (twenty percent of 503 equals 100.6 rounded to the next highest whole number equals 101).


1 The Heart Failure (HF) core measure sampling methodology is applicable to both the HF core measures as well as the ACHF measures.  The HF sampling methodology is shared by CMS and The Joint Commission; however, data collection for the ACHF measures is required by Joint Commission Disease-Specific Care Certification only.

Measure Information Form ACHFOP
Specifications Manual for Joint Commission National Quality Measures (v2018A1)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)

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