Specifications Manual for Joint Commission National Quality Measures (v2020A1)
Posted: 9/13/2019

Home » Venous Thromboembolism (VTE)

Release Notes:
Measure Information Form
Version 2020A1


Venous Thromboembolism (VTE)

Set Measures

Set Measure ID Measure Short Name
VTE-6 Hospital Acquired Potentially-Preventable Venous Thromboembolism

General Data Elements

Element Name Collected For
Admission Date All Records,
Birthdate All Records,
Discharge Date All Records, Not collected for HBIPS-2 and HBIPS-3
Hispanic Ethnicity All Records,
ICD-10-CM Other Diagnosis Codes All Records, Optional for HBIPS-2, HBIPS-3
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 Other Procedure Dates 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 Category Assignment All Records, Calculation, Transmission, Hospital Clinical Data File, Used in calculation of the Joint Commission's aggregate data and in the transmission of the Hospital Clinical Data file.
Payment Source All Records, Optional for HBIPS-2 and HBIPS-3
Race All Records,
Sex All Records,

Algorithm Output Data Elements

Element Name Collected For
Measure Category Assignment All Records, Calculation, Transmission, Hospital Clinical Data File

Measure Set Specific Data Elements

Element Name Collected For
Clinical Trial VTE-6
Comfort Measures Only VTE-6
Reason for No Administration of VTE Prophylaxis VTE-6
VTE Confirmed VTE-6
VTE Diagnostic Test VTE-6
VTE Present at Admission VTE-6
VTE Prophylaxis Status VTE-6


  Document Name  
Acknowledgement  
Appendix A - 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  
Cover Page for the Joint Commission Manual  
Data Dictionary  
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  

Venous Thromboembolism (VTE) Initial Patient Population

The VTE measure set is unique in that there is only one sub-population within the measure set.

Initial Patient Population Definitions Table
Measures Initial Patient Population definition
VTE-6 The count of all patients in sub-population 3

The VTE sub-population utilizes four data elements:

Admission Date
Birthdate
Discharge Date
ICD-10-CM Other Diagnosis Code

Patients admitted to the hospital for inpatient acute care are included in the VTE ICD sub-populations if they have:
1 – No VTE sub-population – is retired.
2 – Principal VTE sub-population – is retired.
3 - Other VTE Only sub-population – Patients with an ICD-10-CM Other Diagnosis Code as defined in Appendix A, Tables 7.03 and 7.04, a Patient Age (Admission Date minus Birthdate) greater than or equal to 18 years, and a Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days. The patients cannot have an ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Tables 7.03 and 7.04.

Initial Patient Population Algorithm

VTE Init Pop_Page1.jpg VTE Init Pop_Page2.jpg

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/month for the sub-population cannot sample that sub-population. Hospitals that have five or fewer discharges for the VTE sub-population (both Medicare and non-Medicare combined) are not required to submit VTE patient level data to the 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 and contraindications, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size.

For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual.

Quarterly Sampling
Sampling for VTE Sub-population 3 – The Other VTE Only sub-population is not eligible for sampling and will use the entire Initial Patient Population for reporting.

To determine if a hospital may choose to not submit VTE patient level data to the Joint Commission’s Data Warehouse, the count of discharges, for the quarter, for the Other VTE Only sub-population must be five or less.

Monthly Sampling
Sampling for VTE Sub-population 3 – The Other VTE Only sub-population is not eligible for sampling and will use the entire Initial Patient Sub-Population for reporting.

Measure Information Form VTE
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Specifications Manual for Joint Commission National Quality Measures (v2020A1)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

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