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Appendix D
Version 2010B

Appendix D

Glossary of Terms

accuracy (of data) The extent to which data are free of identifiable errors.

acute myocardial infarction (AMI) Death of heart muscle resulting from insufficient blood supply to the heart. For purposes of this measure, acute myocardial infarction is identified by the ICD-9-CM codes in Appendix A, Table 1.1.

administrative/billing data (data source) Administrative data are patient-identifiable data used for administrative, regulatory, and payment (financial) purposes. Administrative data generally reflects the content of discharge abstracts (for example, demographic information on patients such as age, sex, zip code; information about the episode of care such as Point of Origin for Admission or Visit, length of stay, discharge status; and ICD-9-CM diagnosis and procedure codes). Namely, the Uniform Bill of the Health Care Financing Administration (UB-04) provides specifications for the abstraction of administrative/billing data.

aggregate (hospital data) Aggregate data elements derived for a specific hospital from the results of each measures algorithm over a given time period (e.g., monthly, quarterly). These data are transmitted to The Joint Commission by performance measurement systems.

algorithm An ordered sequence of data element retrieval and aggregation through which numerator and denominator events or continuous variable values are identified by a measure. The algorithms are depicted using flowcharting symbols.

allowable value A list of acceptable responses for a data element.

ANSI X12 The American National Standards Institute’s standard for transmitting data electronically, or electronic data interchange (EDI).

binary outcome Events or conditions that occur in one or two possible states often labeled 0 or 1. Such data are frequently encountered in medical research. Common examples include dead or alive, and improved or not improved.

cardiac module A set of evidence-based process measures designed to prevent cardiac complications in surgical patients.

caregiver The patient’s family or any other person who will be responsible for care of the patient after discharge.

central tendency A property of the distribution of a variable, usually measured by statistics such as the mean, median, and mode.

cesarean section Surgical delivery of a fetus through incision in the abdominal wall and the uterine wall. Does not include removal of the fetus from the abdominal cavity in case of rupture of the uterus or abdominal pregnancy.

clinical measures Measures designed to evaluate the processes or outcomes of care associated with the delivery of clinical services; allow for intra- and interorganizational comparisons to be used to continuously improve patient health outcomes; may focus on the appropriateness of clinical decision making and implementation of these decisions; must be condition specific, procedure specific, or address important functions of patient care (e.g., medication use, infection control, patient assessment, etc.).

comparison group The group of health care organizations to which an individual health care organization is compared. (Performance measurement systems transmit aggregated comparison group data for non-core measures. The Joint Commission will aggregate health care organization-level data to create the comparison group for each core measure.)

confounding factors Intervening variables that distort the true relationship between/among the variables of interest. They are related to the outcome of interest, but extraneous to the study question and are non-randomly distributed among the groups being compared. They can hide a true correlation or give the appearance of a correlation when none actually exists.

continuous variable An aggregate data measure in which the value of each measurement can fall anywhere along a continuous scale (e.g., the time [in minutes] from emergency department arrival to administration of thrombolysis).

continuous variable data elements Those data elements required to construct the measure as stated in the section labeled “Continuous Variable Statement.”

contraindication A factor or condition that may render the administration of a drug or agent or the performance of a procedure or other practice inadvisable, improper, and/or undesirable.

controllers Controllers are long term control medications for asthma. Controllers reduce airway inflammation and prevent asthma exacerbations. Inhaled corticosteroids are the preferred medications for controlling mild, moderate, and severe persistent asthma. Refer to Appendix C, Table 6.1 for a listing of controller medications.

corticosteroids Any of the hormones produced by the adrenal cortex or their synthetic equivalents, used to achieve quick relief of asthma exacerbations or long term control of the swelling, inflammation and mucus production that occurs when the airway are irritated. Corticosteroids are available in inhaled, topical, oral, and intravenous forms.

critical access hospital (CAH) Is a rural public, non-profit or for-profit hospital: a hospital that was closed within the previous ten years; or is a rural health clinic that was downsized from a hospital that is located in a State that has established a State plan with CMS for the Medicare Rural Hospital Flexibility Program. A CAH makes available 24-hour emergency care services 7 days per week and are, by definition, located more than a 35 mile drive from any other hospital or CAH (in mountainous terrain or in areas with only secondary roads available, the mileage criterion is 15 miles); or is certified by the State in the State plan as being a necessary provider of health care services to residents in the area. They provide no more than 15 beds for acute (hospital-level) inpatient care and provide an annual average length of stay of 96 hours per patient for acute care patients. An exception to the 15-bed requirement is made for swing-bed facilites, which are allowed to have up to 25 inpatient beds that can be used interchangeably for acute or SNF-level care, provided that not more than 15 beds are used at any one time for acute care. Hospitals certified by the Secretary of the Department of Health and Human Services (DHHS) as critical access hospitals are eligible for cost-based reimbursement from Medicare if they meet a specific set of federal Conditions of Participation (CoPs).

data collection The act or process of capturing raw or primary data from a single or number of sources. Also called “data gathering.”

data collection effort The availability and accessibility of the required data elements, the relative effort required, and associated cost of abstracting or collecting the data.

data element A discrete piece of data, such as patient birthdate or principal diagnosis. See also denominator data elements, numerator data elements, continuous variable data elements, and risk adjustment data elements.

data entry The process by which data are transcribed or transferred into an electronic format.

data quality The accuracy and completeness of measure data on performance in the context of the analytic purposes for which they will be used.

data transmission The process by which data are electronically sent from one organization to another. For example a hospital sending patient-level data to its selected performance measurement system, and the system sending measure-level data to The Joint Commission or patient-level data to the QIO Clinical Warehouse.

denominator The lower part of a fraction used to calculate a rate, proportion, or ratio. Also the population for a rate based measure.

denominator data elements Those data elements required to construct the denominator.

depilatories Chemical-based lotions or creams used to dissolve hair at the skin’s surface.

disaster medical assistance team (DMAT) Provides emergency medical assistance following a catastrophic disaster or other major emergency.

discrete variable See rate based measure.

electronic data interchange (EDI) An instance of data being sent electronically between parties, normally according to predefined industry standards.

electrocardiogram (ECG) A graphic tracing of the heart’s electrical impulses.

empiric antibiotic therapy Antibiotic treatment based on the clinician’s judgment and the patients signs and symptoms and offered before a diagnosis has been confirmed.

episode of care (EOC) A patient or case level record submitted to the database.

excluded populations Detailed information describing the populations that should not be included in the indicator. For example, specific age groups, ICD 9 CM procedure or diagnostic codes, or certain time periods could be excluded from the general population drawn upon by the indicator.

extranet A private network using the Internet protocol to securely share business information or operations with vendors, customers, and/or other businesses. “The Joint Commission Connect” is the name given to the Joint Commission’s extranet site.

fibrinolytic therapy Administration of a pharmacological agent intended to cause lysis of a thrombus (destruction or dissolution of a blood clot). Refer to Appendix C, Table 1.5 for a listing of fibrinolytic agents.

format Specifies the character length of a specific data element; the type of information the data element contains: numeric, decimal number, date, time, or alphanumeric; and the frequency with which the data element occurs.

fourth degree perineal laceration A rupture or tear involving anal sphincter, rectovaginal septum, and anal mucosa.

general data elements Data elements that must be collected by hospitals for each patient record. These data are patient demographic data, hospital identifiers, and patient identifiers.

health care organization (HCO) The business entity which is participating in a performance measurement system (e.g., health care organization level data describes information about the business entity).

health care organization (HCO) level data Aggregation of patient level data to summarize the performance of an individual hospital on a performance measure. This data is transmitted to The Joint Commission by the hospital’s performance measurement system.

heart failure (HF) A clinical syndrome characterized by signs and symptoms resulting from disturbances in cardiac output or from increased venous pressure, including fatigue, shortness of breath, or leg swelling. For purposes of this measure, heart failure is identified by ICD-9-CM codes in Appendix A, Table 2.1.

hospital According to the American Hospital Association, hospitals are licensed institutions with at least six beds whose primary function is to provide diagnostic and therapeutic patient services for medical conditions by an organized physician staff, and have continuous nursing services under the supervision of registered nurses.

hospitalist A physician whose main practice provides care for hospitalized patients.

initial patient populations Detailed information describing the population(s) that the indicator intends to measure. Details could include such information as specific age groups, diagnoses, ICD 9 CM diagnostic and procedure codes, CPT codes, revenue codes, enrollment periods, insurance and health plan groups, etc.

infection module A set of evidence-based process measures designed to prevent postoperative infection in the surgical patient

inpatient mortality Any patient death occurring while admitted as an in-patient in the hospital.

invalid data Values for data elements that are required for calculating and/or risk adjusting a core measure that fall outside of the acceptable range of values defined for that data element. Refer to the Missing and Invalid Data section for further information.

“The Joint Commission Connect” The name given to the Joint Commission’s extranet site, a secured online connection to The Joint Commission.

mean A measure of central tendency for a continuous variable measure. The mean is the sum of the values divided by the number of observations.

measure information form Tool to provide specific clinical and technical information on a measure. The information contained includes: performance measure name, description, rationale, numerator/denominator/continuous variable statements, included populations, excluded populations, data elements, risk adjustment, sampling, data accuracy, and selected references.

measure of performance See performance measure.

measurement system See performance measurement system.

median The value in a group of ranked observations that divides the data into two equal parts.

medical record (data source) Data obtained from the records or documentation maintained on a patient in any health care setting (for example, hospital, home care, long term care, practitioner office). Includes automated and paper medical record systems.

military time A 24 –hour period from midnight to midnight using a 4-digit number of which the first two digits indicate the hour and the last two digits indicate the minute.

missing data No values present for one or more data elements that are required for calculating and/or risk adjusting a national hospital quality measure. Refer to the Missing and Invalid Data section for further information.

mode The most frequently occurring response for that data element.

module A set of measures under a common group/topic area (e.g., infection module).

national quality measure A standardized performance measure that meets the Centers for Medicare & Medicaid Services and Joint Commission evaluation criteria, has precisely defined specifications, can be uniformly embedded in extant systems, has standardized data collection protocols to permit uniform implementation by health care organizations and permit comparisons of health care organization performance over time through the establishment of a national comparative data base.

national quality measure set A unique grouping of performance measures carefully selected to provide, when viewed together, a robust picture of the care provided in a given area (e.g., cardiovascular care, pregnancy).

neonatal mortality Death of a live-born neonate before the neonate becomes age 28 days (up to and including 27 days, 23 hours and 59 minutes from the moment of birth).

nosocomial infection An infection acquired by a patient in a health care organization, especially a hospital. This infection is not present or incubating before admission to a hospital.

numerator The upper portion of a fraction used to calculate a rate, proportion, or ratio.

numerator data elements Those data elements necessary or required to construct the numerator.

observed rate The observed rate is the measure rate that is based on a hospital’s aggregated data for the reporting period. This is calculated as the number of measure numerator cases for the reporting period divided by the number of denominator cases. Observed rates are used to measure hospital performances.

oral antibiotics For the purposes of the SCIP measure set, refers to two different combinations of antibiotics by the PO route, which can be given by mouth, NG tube, or PEG tube. Those combinations are either Neomycin and Erythromycin or Neomycin and Flagyl (also called Metronidazole). These combinations are for use in prophylaxis specifically for colon surgery patients. For further information, see Prophylactic Antibiotic Regimen Selection for Surgery table, page SCIP-Inf-2-4.

parenteral Not through the alimentary canal but rather by injection through some other route, as subcutaneous, intramuscular, intraorbital, intracapsular, intraspinal, intrasternal, intravenous, etc.

patient level data Collection of data elements that depict the health care services provided to an individual (patient). Patient level data are aggregated to generate hospital level data and comparison group data.

patient survey (data source) Survey data are exclusively obtained from patients and/or their family members/significant others.

percentile A value on a scale of 100 that indicates the percentage of a distribution that is equal to or below it.

performance measure A quantitative tool (for example, rate, ratio, index, percentage) that provides an indication of an organization’s performance in relation to a specified process or outcome. See the process measure and the outcome measure.

performance measurement system An entity consisting of an automated database(s), that facilitates performance improvement in health care organizations through the collection and dissemination of process and/or outcome measures of performance. Measurement systems must be able to generate internal comparisons of organization performance over time, and external comparisons of performance among participating organizations at comparable times.

pneumonia (PN) Pneumonia is defined as an acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection, accompanied by presence of acute infiltrate on chest radiograph or auscultatory findings consistent with pneumonia (such as altered breath sounds and/or localized rales).

predicted value The statistically expected response or outcome for a patient after the risk adjustment model has been applied and the patient’s unique set of risk factors have been taken into account.

prophylactic antibiotic An antibiotic used to prevent, rather than treat or cure, disease. For the purposes of SCIP-Inf-1-3, antibiotics given to prevent postoperative infection will be collected. Because the overuse of antibiotics can lead to resistance, antibiotics taken to prevent infection should be used only for a short time.

process An interrelated series of events, activities, actions, mechanisms, or steps that transform inputs into outputs.

proportion measure A measure which shows the number of occurrences over the entire group within which the occurrence should take place (e.g., patients delivered by cesarean section over all deliveries).

randomization A technique for selecting or assigning cases such that each case has an equal probability of being selected or assigned. It is done to stimulate chance distribution, reduce the effects of confounding factors, and produce unbiased statistical data.

range A measure of the spread of a data set. The difference between the smallest and largest observation.

rate based (measure) An aggregate data measure in which the value of each measurement is expressed as a proportion or as a ratio. In a proportion, the numerator is expressed as a subset of the denominator (for example, patients with cesarean section, divided by all patient who deliver). In a ratio, the numerator and denominator measure different phenomena (for example, the number of patients with central lines who develop infections divided by the number of central line days).

ratio A relationship between two counted sets of data, which may have a value of zero or greater. In a ratio, the numerator is not necessarily a subset of the denominator (e.g., pints of blood transfused to number of patients discharged).

reliability The ability of the indicator to accurately and consistently identify the events it was designed to identify across multiple health care settings.

relievers Relievers are used to quickly alleviate bronchoconstriction. Relievers relax the bands of muscle that surround the airways. Relievers are also known as rescue, quick relief, or short-acting medications of choice to quickly relieve asthma exacerbations. Relievers include short acting beta2 agonists and anticholinergics. Refer to Appendix C, Table 6.2 for a listing of reliever medications.

Reporting Hospital Data for Annual Payment Update The Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) initiative is intended to empower consumers with quality of care information to make more informed decisions about their health care, while encouraging hospitals and clinicians to improve the quality of inpatient care provided to all patients. The hospital quality of care information gathered through the RHQDAPU initiative is available to consumers on the Hospital Compare website.

reporting period The defined time period which describes the patient’s end of service.

reperfusion Reestablishing blood flow in an obstructed coronary artery. It may be accomplished with thrombolytic therapy or percutaneous coronary intervention.

risk adjusted measures Measures that are risk adjusted using statistical modeling or stratification methods.

risk adjusted rate A rate that takes into account differences in case mix to allow for more valid comparisons between groups.

risk adjustment A statistical process for reducing, removing, or clarifying the influences of confounding factors that differ among comparison groups (for example, logistic regression, stratification).

risk adjustment data elements Those data elements used to risk adjust a performance measure (e.g., reduce, remove, or clarify the influences of confounding patient factors that differ among comparison groups). Such data elements may be used exclusively for risk adjustment (e.g., not required to construct the numerator or denominator) or may be required for numerator or denominator construction as well as risk adjustment.

risk adjustment model The statistical algorithm that specifies the numerical values and the sequence of calculations used to risk adjust (e.g., reduce or remove the influence of confounding factors) performance measures.

risk factor A factor that produces or influences a result. In statistics, an independent variable used to identify membership of qualitatively different groups. Refer to Appendix B for risk factor definitions.

risk factor value A specific value assigned to a risk factor for a given episode of care (EOC) record.

risk model The statistical algorithm that specifies the numerical values and the sequence of calculations used to risk adjust (e.g., reduce or remove the influence of confounding factors) performance measures.

sampling frequency If a hospital chooses to sample, they may sample data on either a monthly or quarterly basis. Refer to the “Sample Size Requirements” discussion in the Population and Sampling Specifications section for further information.

sampling method Describes the process used to select a sample. Sampling approaches for national hospital quality measures are simple random sampling, and systematic sampling. Refer to the “Sampling Approaches” discussion in the Population and Sampling Specifications section for further information.

sample size The number of individuals or particular patients included in a study. Usually chosen so that the study has a particular statistical power of detecting an effect of a particular size. Refer to the “Sample Size Requirements” discussion in the Population and Sampling Specifications for further information.

score A rating, usually expressed as a number, and based on the degree to which certain qualities or attributes are present (e.g., Glascow coma, ASA scores).

severity The degree of biomedical risk, or mortality of medical treatment.

simple random sample A process in which a sample of data is selected from the total population in such a way that every case has the same chance of being selected and that the sample size is met. Refer to the “Sampling Approaches” discussion in the Population and Sampling Specifications section for further information.

standard deviation A measure of variability that indicates the dispersion, spread, or variation in a distribution.

strata See stratified measure.

stratification A form of risk adjustment which involves classifying data into strata based on one or more characteristics, variables, or other categories.

stratification based approach for risk adjustment The process of dividing or classifying subgroups known as strata in order to facilitate more valid comparisons. For example, a measure’s outcome may be divided into type of surgery-specific categories or strata.

stratified measure A performance measure that is classified into a number of strata to assist in analysis and interpretation. The overall or un-stratified measure evaluates all of the strata together. The stratified measure or each stratum consists of a subset of the overall measure. For example, surgical patients who received a prophylactic antibiotic within one hour prior to surgical incision is reported as all surgical patients with the appropriate ICD-9-CM Principal Procedure Code who received the prophylactic antibiotic within one hour prior to surgical incision; however, the stratified measure(s) for SCIP-Inf-1 is reported by the specific ICD-9-CM Principal Procedure, such as CABG (SCIP-Inf-1b) or Other Cardiac Surgery (SCIP-Inf-1c).

stratum See stratified measure.

sub-population A population that is part of a larger population. For example, the measure set Pregnancy and Related Conditions evaluates the obstetrical population in the hospital. This measure set is broken into two distinct sub-populations, mothers (PR-1 and PR-3) and neonates (PR-2).

surgical care improvement project (SCIP) The Surgical Care Improvement Project (SCIP) is a national quality partnership of organizations focused on improving surgical care by significantly reducing surgical complications through performance measurement. Utilizing nine process measures in three separate modules (infection, cardiac, and VTE), the goal is to reduce the incidence of surgical complications nationally by 25 percent by the year 2010.

surgical infection prevention (SIP) In August of 2002, the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention collaborated to develop the Surgical Infection Prevention project. The Medicare Surgical Infection Prevention Project was started with the single objective - to decrease morbidity and mortality associated with postoperative infection in the Medicare patient population. As of July 2006 discharges, the three SIP measures become the first three SCIP infection measures.

systematic random sampling A process in which the starting case is selected randomly, and the next cases are selected according to a fixed interval that is based upon the number of cases in the population. For example, the starting case is the second patient that arrives at the hospital. This patient and every subsequent fifth patient becomes part of the random sample until the sample size is reached. Refer to the “Sampling Approaches” discussion in the Population and Sampling Specifications section for further information.

systemic corticosteroids Corticosteroids are hormones produced by the adrenal cortex or their synthetic equivalents and are administered orally or intravenous. Corticosteroids are used to achieve quick relief of acute or moderate to severe asthma exacerbations. Oral corticosteroids are also used for long term control of the swelling, inflammation and mucus production in the airways. Refer to Appendix C, Table 2.15 for a listing of PN systemic corticosteroid medications or Table 6.3 for a listing of CAC systemic corticosteroid medications.

third degree perineal laceration A rupture or tear in the perineum involving the anal sphincter and rectovaginal septum.

thrombolytic therapy See fibrinolytic therapy

transmission schedule The schedule of dates on which data are expected to be transmitted to The Joint Commission and the QIO Clinical Warehouse.

Unable to be determined (UTD) Each data element that is applicable per the algorithm for each of the measures within a topic must be “touched” by the abstractor. While there is an expectation that all data elements are collected, it is recognized that in certain situations information may not be available (i.e., dates, times, codes, etc.). If, after due diligence, the abstractor determines that a value is not documented or is not able to determine the answer value, the abstractor must select “Unable to Determine (UTD)” as the answer.

vaccine A vaccine is a suspension of an attenuated (weakened) or killed microorganism, such as bacteria or virus, administered for the prevention, amelioration, or treatment of infectious diseases.

vaginal birth after cesarean section (VBAC) A successful trial of labor resulting in a vaginal birth on a patient with a history of cesarean section.

validation The process by which the integrity and correctness of data are established. Validation processes can occur immediately after a data item is collected or after a complete set of data are collected. The Centers for Medicare & Medicaid Services (CMS) chart level validation will validate the data at several levels. There are consistency and internal edit checks to assure the integrity of the submitted data; there are external edit checks to verify expectations about the volume of the data received, and, there will be chart level audits to assure the reliability of the submitted data. Information on these procedures is available on www.qnetexchange.org.

validity Ability to identify opportunities for improvement in the quality of care; demonstration that the indicator use results in improvements in outcomes and/or quality of care.

variance Equal to the square of the standard deviation.

venous thromboembolism (VTE) module A set of evidence-based process measures designed to prevent VTE in surgical patients.

verification The process used to ensure consistent implementation of core measure algorithms specified in this manual across disparate measurement systems.

Selected Sources:

Babbie, ER, The Practice of Social Research, 2nd edition, Belmont, CA: Wadsworth Publishing Company, 1979.

Everitt, BS, The Cambridge Dictionary of Statistics, Cambridge University Press, 1998.

Iezonni, LI, Foley, SM, Heeran, T, Daley, J, Duncan, CC, Fisher, ES, Hughes, J, “A Method for Screening the Quality of Hospital Care Using Administrative Data: Preliminary Validation Results,” Quality Review Bulletin, November, 1992, 361 370.

Lexikon Second Edition, Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, 1998.

McHorney, CA, Kosinski, M, and Ware, Jr., JE, “Comparisons of the Cost and Quality of Norms for the SF 36 Health Survey Collected by Mail Versus Telephone Interview: Results From a National Survey,” Medical Care, 32, (1994), 551 567.

Nichols, T and Earl, L, Basic ICD 9 CM Coding Handbook, Chicago, IL: American Health Information Management Association, 1992.

ORYX® Technical Implementation Guide, Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, current.

2006 Accreditation Manual(s), Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, 2005.

Related Topics

Related Topics
a. Table of Contents

Appendix D
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)