Note: Regarding PaS data submission, CSTK Follow-up file does not affect the population size. No PaS file is expected in the quarter that Follow-up file is submitted.

Starting from 1Q2019 discharged data, STK patient can be inpatient or outpatient. But each STK inpatient or outpatient case must have a separate XML file. A patient cannot be inpatient and outpatient at the same time, therefore cannot be combined into the same XML file.

• Outpatient XML must have Outpatient Encounter Date and E/M Code.

Starting from 3Q2018 discharged data, ASR patient can be inpatient or outpatient. But each ASR inpatient or outpatient case must have a separate XML file. A patient cannot be inpatient and outpatient at the same time, therefore cannot be combined into the same XML file.

• ASR outpatient measure (ASR-OP-1, ASR-OP-2) are submitted in one XML file with measure-set= “ASR-OP”

• Outpatient XML must have Outpatient Encounter Date and E/M Code.

• Unique Key Identifier for Discharge Measures (e.g., HBIPS-1, PC-01, CSTK-03, ASR-IP-1):
  • 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 (i.e., HBIPS-2 and HBIPS-3, CSTK-10 or CSTK-02):
  • 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

• Unique Key Identifier for Outpatient Measures (e.g., ASR-OP-1, STK-OP-1):
  • 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
  • Arrival Time
  • Encounter Date
  • 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) but cannot be transmitted to The Joint Commission for any measure because the data transmitted to The Joint Commission are anonymous. Files transmitted to The Joint Commission that contain the following data will be rejected:
  • Patient Identifier
  • 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 measure set.
  • Measure Category Assignment
  • Measurement Value (Note: Currently there is no active Continuous Variable measure in The Joint Commission Manual that uses this data element)
  • Predicted Value
  • Vendor Tracking ID
    
    *Note* — Vendor Tracking ID is a fictitious identifier that 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. Vendor Tracking ID data element is used to transmit this fictitious identifier. 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, PC-01, CSTK-05, ASR-IP-1).
  • Vendor Tracking ID
  • Admission Date
  • Discharge Date
  • Birthdate
  • Health Care Organization Identifier
    For example, if the hospital submits a separate XML file for STK, PC, HBIPS, and TOB, the above identifiers should be the same in each of the discharge XML files.

• For HBIPS or CSTK records, if the patient has multiple events(e.g., HBIPS-2 and HBIPS-3, CSTK-10 or CSTK-02), 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. 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

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 four quarters of Hospital Clinical data (HCD) and Population and Sampling data (PaS). 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 four quarters of updated HCD and PaS data for national quality measures by the next regularly scheduled quarterly transmission deadline. Retransmission of corrected 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, and update the national comparison group rates.
  
  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 ORYX Vendors

• ORYX Vendors will have access to current national quality 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 measure risk models must not be used for any purposes other than calculating risk-adjusted data elements.
• For assistance with the national quality measure risk model information, please contact the ORYX statistical support staff at http://manual.jointcommission.org and click on Statistical Support.

• 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 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

• 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, e.g., “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).

Joint Commission Guidelines for Submission of Hospital Clinical Data

• Download TJC_Allowable_Measure_Sets_Combination (MS Excel)

* If the abstractor, after due diligence, is not able to determine an answer, a value of “UTD” must be selected for the applicable data element. This includes ICD-10-PCS Principal Procedure Date and ICD-10-PCS Other Procedure Dates, which are required data elements if ICD-10-PCS Principal Procedure Code and ICD-10-PCS Other Procedure Codes are submitted for the case. Please see the data element definitions for further details on allowable values. If the case is missing the corresponding allowable answer value, the case will be rejected from the Joint Commission’s Data Warehouse.

• Patient Identifier
• First Name
• Last Name
• Postal Code

• Measure Category Assignment
• Measurement Value (Note: Currently there is no active Continuous Variable measure which uses this data element)
• Predicted Value

1. Vendor Tracking ID
2. Admission Date
3. Discharge Date
4. Birthdate
5. Health Care Organization Identifier

1. Vendor Tracking ID
2. Admission Date
3. Birthdate
4. Health Care Organization Identifier

Refer to the Transmission Alpha Data Dictionary for more information concerning the Vendor Tracking ID and Health Care Organization Identifier.

1. Type – Describes the setting for which the data is being collected (Hospital or Outpatient)
2. Data – Describes the type of data being submitted (Clinical).
3. Version – Describes the version of the XML file layout.
4. Action-Code – Describes the action intended with the submission of the file. Options include:
   1. Add (applicable to a file submitted for the first time for the hospital/time period or to a file being submitted as an update/replacement of an existing file already submitted for a provider).
   2. Delete (utilize when the file is submitted for the purpose of deleting a file already submitted to the Joint Commission’s Data Warehouse.)

1. Create-Date – Indicates the date the file was created.
2. Create-Time – Indicates the time the file was created.
3. Create-By – Indicates who created the file.
4. Version – Indicates the version of the file being submitted.
5. Create-by-Tool – Indicates the software tool utilized to create the file.

1. Abstraction-Date – Indicates the date the file was abstracted.
2. Abstractor-id – Indicates the person who abstracted the file.
3. Total-Abstraction-Time – Indicates the time required to abstract the file (in seconds).
4. Comments – Area for entry of any comments regarding the abstraction.

1. CMS Certification Number - Hospital’s six digit acute CMS Certification Number (CCN), which is allowed and is optional for The Joint Commission.
2. NPI - National Provider Identifier as assigned by CMS, optional for The Joint Commission.
3. HCOID - Identifies the healthcare organization that is accredited by The Joint Commission and is required as a key element of the patient file for The Joint Commission.

1. Admission Date (for hospital measures)
2. Discharge Date (for hospital measures)
3. Encounter date (for outpatient measures)
4. Arrival Time (for outpatient measures)
5. Event Date (event measures)
6. Event Type (event measures)
7. Vendor Tracking Identifier
8. Measure Set
9. Clinical Questions and answer codes

1. Measure Category Assignment
2. Measurement Value (Note: Currently there is no active Continuous Variable measure which uses this data element)
3. Predicted Value

Please refer to the data dictionary for further definition of these data elements.

Abstraction Software Skip Logic and Missing Data

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 or Outpatient Initial Patient Population Data

1. Type — Describes the setting for which the data is being collected (Hospital or Outpatient)
2. Data — Describes the type of data being submitted (Population).
3. Version — Describes the version of the XML file layout.
4. Action-Code — Describes the action intended with the submission of the file. The “Add” action-code is required for all initial patient population files submitted.

1. Create-Date — Indicates the date the file was created.
2. Create-Time — Indicates the time the file was created.
3. Create-By — Indicates who created the file.
4. Version — Indicates the version of the file being submitted.
5. Create-by-Tool — Indicates the software tool utilized to create the file.

1. Provider-Id - Hospital's six digit acute care CMS Certification Number (CCN), which is allowed and it's optional for The Joint Commission.
2. NPI - National Provider Identifier as assigned by CMS, and is optional for The Joint Commission.
3. HCOID - Identifies the healthcare organization that is accredited by The Joint Commission and is required as a key element of the patient file.

1. Measure-Set — Indicates the Measure Set for which the data is being submitted.
2. Stratum — Indicates the stratum (e.g., HBIPS) or sub-population (e.g., PC) related to the data being submitted.