Release Notes:
Using The Manual TJC
Version 2010A1
Using The Specifications Manual for Joint Commission National Quality Core Measures
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 core measures. The sections of this manual are interrelated and are most useful when considered together.
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 2 - Measurement Information
The
HBIPS and
PC 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 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 core 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.
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 and on submission into the Joint Commission’s Data Warehouse. 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.
Sampling is an available option for all Joint Commission national quality core 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 transmission of Initial Patient Population and sample data elements to the Joint Commission’s Data Warehouse.
Section 5 – Joint Commission National Quality Core Measure Verification Process
This section has been moved to the
ORYX Technical Implementation Guide and is available to ORYX Vendors via the
Joint Commission’s extranet site for measurement systems (PET).
This section of the manual is provided to highlight the unique data transmission specifications for Joint Commission national quality core measure data. This section is divided into four parts: Joint Commission National Quality Core Measure Data Transmission, Guidelines for Submission of Data, Transmission Data Element List, and Transmission Data Processing Flow.
The Joint Commission Data Transmission section provides information related to the transmission of Joint Commission national quality core 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 core measures and the population and sampling data.
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-9-CM diagnosis and procedure codes within the patient-level record. Appendix A contains the ICD-9-CM 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-9-CM 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.
Some of the Joint Commission natioanl quality core 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.
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.
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. For example, the Discharge Status Inclusion Table is used to supplement abstraction guidelines for HBIPS 7 (Post Discharge Continuing Care Plan Transmitted to Next Level of Care Provider upon Discharge).
This section lists resources that are available to assist with the Joint Commission measures.
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