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.
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.
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.
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.
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