Introduction

This section of the manual is provided to highlight the unique data specifications for The Joint Commission national quality measure data.

The Data Processing section provides information related to the national quality measure data submitted to the Joint Commission.

The Data Processing Flow contains information regarding the order in which the Joint Commission recommends evaluation of the national hospital quality measures. In addition, it highlights the decision points as to when cases should be rejected from further processing.

The Joint Commission National Quality Measure Data

Overview

The Joint Commission no longer receives patient level data for the chart-based national quality measures.

For accreditation purposes, the data can only be submitted as aggregated numbers through the Joint Commission’s Direct Data Submission Platform (DDSP). For more information concerning aggregate data required for accreditation reporting, refer to documentation available on the DDSP. This documentation includes details on the specific aggregate data required for each chart-based measure and information concerning how to calculate the data.

For certification purposes, hospitals will manually enter their aggregate numerator and denominator data on the Certification Measure Information Process (CMIP) application available on JC Connect®. Submit your questions concerning the CMIP application and the certification process to your Joint Commission Certification Account Executive.

Data submission for different Stroke certification programs

Following table depicts the measures that are required for each certification program:

Joint Commission Stroke Certification Measure Table
Effective for discharges on and after July 1, 2022

	Primary Stroke Center (PSC) Without MT	Primary Stroke Center (PSC) With MT	Thrombectomy-capable Stroke Center (TSC)	Comprehensive Stroke Center (CSC)	Acute Stroke Ready (ASR)
STK-1	X	X	X	X
STK-2	X	X	X	X
STK-3	X	X	X	X
STK-4	X	X	X	X
STK-5	X	X	X	X
STK-6	X	X	X	X
STK-8	X	X	X	X
STK-10	X	X	X	X
STK-OP-1	X	X			X
STK-OP-1a	Not Reported	Not Reported			Not Reported
STK-OP-1b	X	X			X
STK-OP-1c (Retired effective July 1, 2021)	Not Reported	Not Reported			Not Reported
STK-OP-1d	X	X			X
STK-OP-1e	X	X			X
STK-OP-1f	X	X			X
STK-OP-1g	X	X			X
STK-OP-1h	X	X			X
STK-OP-1i	X	X			X
STK-VOL-1	X	X
CSTK-01	X	X	X	X
CSTK-02		X
CSTK-03 (Overall) CSTK-03a CSTK-03b				X
CSTK-04				X
CSTK-05 (Overall) CSTK-05a CSTK-05b		X	X	X
CSTK-06				X
CSTK-08		X	X	X
CSTK-09 (Overall) CSTK-09a CSTK-09b		X	X	X
CSTK-10 (Overall) CSTK-10a CSTK-10b CSTK-10c CSTK-10d			X	X
CSTK-11				X
CSTK-12				X
ASR-IP-1					X
ASR-IP-2					X
ASR-IP-3					X
ASR-OP-1					X
ASR-OP-2 (Retired effective July 1, 2021)					Not Reported
ASR-OP-2a					Not Reported
ASR-OP-2b					Not Reported
ASR-OP-2c					Not Reported
ASR-OP-2d					Not Reported

Submission of CSTK Data
This measure set is reported for three certification programs, Comprehensive Stroke Center (CSC) certification, Thrombectomy-capable Stroke Center (TSC) Certification, and Primary Stroke Center (PSC) Certification. CSTK data is different from other measure sets since discharged patient requires follow-up within a certain number of days after the discharge date. The CSTK-05 measure has been used as the benchmark to define which records require a follow-up. Certification programs, Comprehensive Stroke Center (CSC), Thrombectomy-capable Stroke Center (TSC), and Primary Stroke Center (PSC) With MT require follow-ups after their first discharge visit, but Primary Stroke Center (PSC) Without MT Certification does not require a follow-up.

Sites with CSC certification

Following points provide the detail of how a CSTK file is expected and processed, specifically for CSC certification:

a. All CSTK measures with the exception of CSTK-10 must be reported for the month the patient was discharged. CSTK-10 must be reported for the month that patient follow-up occurred to obtain the Modified Rankin Score (mRS).

b. All cases that have category assignment of E (in numerator) or D (in denominator) for the CSTK-05 measure are expected to have a follow-up mRS in the specific timeframe window (i.e., 75 to 105 days after the discharge date).

c. The aggregate numbers for CSTK-10, must be submitted for the month that follow-up happened.

Note:
a. For a patient who expired during hospitalization, the mRS Date and Event date should report the discharge date.
b. For a patient who expired after discharge date, the mRS date and event date both should be the date hospital was informed of the death and not the actual date of death.

Example:
The CSTK-10 measure flow assigns E if the follow-up date is between 75 to 105 days after the discharge date and assigns D to any follow-up date before or after the window (before 75 days or after 105 days) of the discharge date.

The following scenario should clarify the details of the follow-up data submission for such a CSTK case:

a. Case 1 has been discharged from a CSC certified site with a discharge date of January 1st, 2020. The case is processed and aggregated for CSTK-05 for January submission. Assuming CSTK-05 result is E, 75-105 days later, a follow-up is required.

b. Jan 1st + 75= March 17th, 2020, is the earliest expected date of follow-up and Jan 1st+105= April 16th, 2020 is the latest expected date of follow-up.

c. If the follow-up occurred on March 17th, then it happened in the same quarter (1Q2020) as the Jan 1st discharge date. In this scenario, CSTK-10 measure result is E since the follow-up happened within the 75-105 day window. This case should be counted and aggregated for the month of March.

Sites with TSC certification

The data processing for TSC certification is similar to data processing for CSC certification as discussed above, except for the following:

• When these sites report a discharged CSTK case, they should only report the results for 4 of the 10 CSTK measures. (i.e., CSTK-01, CSTK-05, CSTK-08, CSTK-09).
• The follow-up measure for TSC is CSTK-10.

Sites with PSC certification (With MT)

The data processing for PSC certification is similar to data processing for CSC certification as discussed above, except for the following:

• When these sites report a discharged CSTK case, they should only report the results for 4 of the 10 CSTK measures. (i.e., CSTK-01, CSTK-05, CSTK-08, CSTK-09).
• The follow-up measure for PSC With MT is CSTK-02.

Sites with PSC certification ( Without MT)

• When these sites report a discharged CSTK case, they should only report the results for the CSTK-01 measure.

STK data section

Starting from 1Q2019 discharged data, STK patient can be inpatient or outpatient.

• STK inpatient measures (STK-01, 02, 03, 04, 05, 06, 08 and 10)
• STK outpatient measure (STK-OP-1)
• A patient cannot be an inpatient and outpatient at the same time, therefore the same patient cannot be counted in both the inpatient and outpatient STK measures.

ASR data section

Starting from 3Q2021 discharged data, ASR patient can be inpatient or outpatient.

• ASR inpatient measures (ASR-IP-1, 2 and 3)
• ASR outpatient measure (ASR-OP-1)
• STK Outpatient measure (STK-OP-1)
• A patient cannot be an inpatient and outpatient at the same time, therefore the same patient cannot be counted in both the inpatient and outpatient ASR measures.

CCC data section

Data submission for different Cardiac programs

The following are the standardized performance measures abstracted for the Comprehensive Cardiac Care (CCC) certification program:

Joint Commission Comprehensive Cardiac Center Certification Measure Table

	Mandatory Comprehensive Cardiac Center Certification Performance Measures
CCCIP-01	High-Intensity Statin Prescribed at Discharge
CCCIP-02	Aldosterone Antagonist Prescribed at Discharge
ACHF-01	Beta-Blocker Therapy (i.e. Bisoprolol, Carvedilol, or Sustained Release Metoprolol Succinate) Prescribed for LVSD at Discharge
ACHF-02	Post-Discharge Appointment for Heart Failure Patients
ACHF-06	Post-Discharge Evaluation for Heart Failure Patients

	Optional Inpatient Comprehensive Cardiac Center Certification Performance Measures
CCCIP-03	Cardiac Rehabilitation Referral from an Inpatient Setting
CCCIP-04	Cardiac Rehabilitation Referral for Heart Failure Patients with Reduced Ejection Fraction from Inpatient Setting
CCCIP-05	Cardiac Rehabilitation Enrollment - Inpatient

	Optional Outpatient Comprehensive Cardiac Center Certification Performance Measures
CCCOP-01	Cardiac Rehabilitation Referral from an Outpatient Setting
CCCOP-02	Cardiac Rehabilitation Referral for Heart Failure patients with Reduced Ejection Fraction from an Outpatient Setting
CCCOP-03	Cardiac Rehabilitation Enrollment - Outpatient
ACHFOP-03	Hospital Outpatient Aldosterone Receptor Antagonists Prescribed for LVSD
ACHFOP-06	Hospital Outpatient Discussion of Advance Directives/Advance Care Planning

Additional Measures Processing Information

Risk Adjustment:
Note: Risk adjustment has been suspended as of January 1st, 2020. The Joint Commission risk adjustment information is available in the Risk Adjustment Guide.

• For assistance with the national quality measure risk guide, please contact the Joint Commission’s performance measurement statistical support staff at http://manual.jointcommission.org and click on Statistical Support.

Missing Data Policy
Abstracted cases must have all data required to calculate the measures. Any case, which is missing data required to calculate measures and would result in a Measure Category “X” assignment, should not be used in data aggregation for any of the measures in the measure set for that record. These cases should be reviewed by the provider and re-evaluated for an allowable value indicated for any data element that was missing. Please refer to the Missing and Invalid Data Section for additional information.

* 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 should not be counted in the aggregation of the measure.

Calculating Patient Age
For algorithms that calculate the patient age, Admission Date minus the Birthdate, use the month and day portion of admission date and birthdate to yield the most accurate age. The traditional approach of counting months or years by the birthday date or the first day of the next month, when the exact date does not exist in the calendar for the end point, must be used when calculating the patient age. For example, if calculating the age by year, a patient born on March 31st turns one year older on March 31st. A patient born on February 29th, in a leap year, has a birthday on February 29th on all leap years, and March 1st in all non-leap years. Or if calculating age by month, if a patient is born on March 31st the patient turns 6 months on October 1st and not on September 30th. Since the date 31 does not exist in September, you would move to the first day of the next month, which would be October 1st, to add one month to the patient age.

Abstraction Software Skip Logic and Missing Data

Skip logic allows hospitals to minimize abstraction burden by using the software edit logic to bypass abstraction of data elements not utilized in the measure algorithm. However, these bypassed elements also negatively impact data quality when elements are incorrectly abstracted and subsequent data elements are bypassed and left blank.

The use of skip logic by hospitals 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. 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 Aggregate Data

For accreditation purposes, hospitals must submit to The Joint Commission the aggregate population and sample counts for each of the measure sets. For more information concerning aggregate data, including population and sample counts, required for accreditation reporting, refer to documentation available on the Joint Commission’s Direct Data Submission (DDS) Platform. This documentation includes details on the specific aggregate data required for each chart-based measure and information concerning how to calculate the data.

For certification purposes, hospitals do not submit their initial patient population or sampling data.