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Data Collection HCSS
Version 2010A1

Data Collection And Data Reporting

Data Collection

Data collection is the continuous process of gathering data points according to the measure specifications established for each of the three standardized HCSS measures. Data may be collected for additional non-standardized measures, if the firm chooses to monitor other indicators not included in the standardized measure set. All certified HCSS firms should be collecting data for all three standardized measures. Data collection for non-standardized measures may be used to enhance the firm’s performance improvement plan, but cannot be used to replace or substitute for data collection for the standardized measures.

Ideally, firms should be collecting data for each of the three standardized measures every month; however, other schedules can be utilized (i.e. quarterly) with the provision that monthly data points are gathered and reported (e.g. graphs and/or tables with data plotted for every month of the calendar year.) Firms that do not prospectively collect data due to resource or other constraints should take steps to ensure that the appropriate number of personnel files is reviewed and findings displayed for each month.

A firm reviews 60 personnel files for HCSS-3: “Completeness of Personnel File” third quarter performance measure data in October. The files selected should include 20 from active clinical staff on the roster in July, 20 from active clinical staff in August, and 20 from active clinical staff in September. All 60 records should not be pulled from active clinical staff on the roster in October, leaving gaps in monitoring for other months.

Data Reporting

Data reporting is a periodic event that provides the HCSS firm with an opportunity to share the findings and analyses of its data collection efforts with internal staff members, other divisions, or branch sites. Data reporting at intervals determined by The Joint Commission is also a requirement for HCSS certification.

Data reported to The Joint Commission should include the numerator and denominator figures for each measure, not just rates. Generally, the numerator is the smaller of the two numbers, and the denominator is the larger. The Performance Measure Data Report (see Appendix-5) is used to report data to The Joint Commission at the time of intra-cycle review and recertification. Graphic data displays should be used to demonstrate further analyses and included as part of the periodic data report. Data reporting should be done on a calendar year, rather than fiscal year basis.

Related Topics

Related Topics
a. Table of Contents for HCSS Manual

Data Collection HCSS
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)