Using The Specifications Manual for Joint Commission National Quality Measures

Table of Contents

Section 1 and 2: Measurement Information
Section 3: Data Dictionary
Section 4: Missing and Invalid Data
Section 5: Population and Sampling Methods
Section 6: Reserved for future use
Section 7: Measures Processing
Appendix A: Code Tables
Appendix C: Medication Tables
Appendix D: Glossary of General Terms
Appendix E: Overview of Measure Information Form and Flowchart Formats
Appendix G: Resources
Appendix H: Miscellaneous Tables
Appendix P: Preview Section

This portion of The Specifications Manual provides a brief overview of the information contained within each section of the manual. It is intended for use as a quick reference to assist in the implementation of the Joint Commission national quality measures. The sections of this manual are interrelated and are most useful when considered together.

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.

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.

Section 1 and 2: Measurement Information

The measure set sections contain specific measure information forms for each measure. This is followed by a data element list for the measures, including the general data elements, algorithm output data elements, and the specific measure data elements. Next is a document that describes the initial patient population and sample size requirements for each measure set. Also included are subsections for each specific measure. These contain a Measure Information Form (MIF) and the Performance Measure Algorithm.

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.

Section 3: Data Dictionary

The Data Dictionary describes the patient-level and facility-level data elements required to capture and calculate individual measurements. It specifies those data elements that must be collected for each patient that falls into the selected measure population and the data elements needed for a specific measure.

Section 4: Missing and Invalid Data

This section addresses the Joint Commission's approach to missing and invalid data. Missing data refers to data elements that have no values present for one or more episodes of care and invalid data refers to data element values that fall outside the range of the allowable values. Information and examples are provided on how the “Unable to Determine” (UTD) value is utilized within the measure algorithm. This section also describes the general and measure specific data elements that are required for submission and how missing and/or invalid data will be handled.

Section 5: Population and Sampling Methods

Sampling is an available option for Joint Commission national quality measures if certain requirements are met. This section provides guidance on defining the hospital's Initial Patient Population and information and examples on the order of data flow, sample size requirements, sampling approaches and the submission of Initial Patient Population and sample as applicable, to the Joint Commission's DDSP site. Specific measure set sample size requirements tables are located in the Measure Information section.

Section 6: Reserved for future use

Section 7: Measures Processing

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

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

Appendix A: Code Tables

For many of the measures, eligibility for inclusion or exclusion in the Initial Patient Population of interest is defined by the presence of certain ICD-10-CM diagnosis and ICD-10-PCS procedure codes within the patient-level record. Appendix A contains the ICD-10 code tables that define these indicator populations for all measures within each measure set. There is a description of the code as defined in a coding manual and a shortened description that may be used in a data abstraction tool. The Measure Information Section also refers to the codes or tables provided in this section. ICD-10 codes are modified by the National Center for Health Statistics (NCHS) and the Centers for Medicare & Medicaid Services (CMS). The code tables in this Appendix are evaluated semiannually and modified based on these changes. Potential changes become effective beginning with either April 1st or October 1st discharges. Updates will be provided as indicated.

Appendix C: Medication Tables

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.

Appendix D: Glossary of General Terms

Appendix E: Overview of Measure Information Form and Flowchart Formats

Each measure has an associated Measure Information Form and Flowchart (calculation algorithm). This Appendix explains each of the terms used on the Measure Information Form and provides a brief introduction to flowcharting, including an explanation of flowchart symbols.

Appendix G: Resources

This section lists resources that are available to assist with the Joint Commission measures.

Appendix H: Miscellaneous Tables

The tables in this Appendix contain clinical information to supplement the data element dictionary and provide additional details for data abstraction. They are referenced under the data dictionary under the Notes for Abstraction or the Guidelines for Abstraction.

Appendix P: Preview Section

The preview section is intended to provide an overview of future updates. The information provided in this section is not to be programmed or submitted. Placement in this appendix does not assume that the information listed will be implemented in a future manual.

Specifications Manual for Joint Commission National Quality Measures (v2023B)
Discharges 07-01-23 (3Q23) through 12-31-23 (4Q23)

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