National Hospital Quality Measure Data Transmission

Introduction

This section of the manual is provided to highlight the unique data transmission specifications for national hospital quality measure data for The Joint Commission compared to the Centers for Medicare & Medicaid Services (CMS) and the QIO Clinical Warehouse.

This section is divided into five parts: Joint Commission National Hospital Quality Measure Data Transmission, CMS National Hospital Quality Measure Data Transmission Guidelines for Submission of Data, Transmission Data Element List, and Transmission Data Processing Flow.

The Joint Commission section provides information related to the transmission of national hospital quality measure data to the Joint Commission’s Data Warehouse.

The CMS transmission section provides the user with the data standards required for submission to the QIO Clinical Warehouse.

The Guidelines for Submission of Data includes an overview of the data required to be submitted to the QIO Clinical Warehouse and 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 Flow contains information regarding the order in which both the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse evaluates the national hospital quality measures. In addition, it highlights the processing differences between the two warehouses.

Joint Commission National Hospital Quality Measure Data Transmission

Overview

The Joint Commission requires three different data transmissions related to the national hospital quality measure data. All of these transmissions are submitted by performance measurement systems and follow the same data transmission schedule used to submit ORYX data to The Joint Commission. The most significant items related to the transmission of national hospital quality measure data are listed here, but this is not an exhaustive list. Refer to the appropriate documents as detailed below for more information.

• Download Hospital Clinical Data XML File Layout (MS Excel)

• Download ICD Population XML File Layout (MS Excel)

Hospital Initial Patient Population Data

The Joint Commission collects Initial Patient Population and sampling information by Measure Set. This data is required to be submitted to The Joint Commission on a quarterly basis. All Initial Patient Population and sampling data will be submitted in an XML file that adheres to the Hospital Initial Patient Population Data XML File Layout specifications and guidelines provided later in this section. Each file may contain data for only one provider.

Hospital Clinical Data

Hospital clinical data is required to be submitted to The Joint Commission no less than on a quarterly basis. All patient-level data submitted to The Joint Commission must adhere to the Hospital Clinical Data XML File Layout specifications and guidelines provided later in this section. The hospital clinical data submitted to The Joint Commission is anonymous because no hospital identifiers or direct patient identifiers are included in the Hospital Clinical Data XML File.

Each case must have a separate XML file. For example, if 12 records have been abstracted, there must be 12 separate XML files. If more than one measure set has been abstracted for a single patient stay, then a separate XML file must be created for each measure set. Each measure set can only be abstracted once for the same medical record.

The Joint Commission will utilize the same XML file layout, guidelines, and edits as CMS with the following exceptions:

• Unique Key Identifier: The Joint Commission’s Data Warehouse uses a different key identifier than the QIO Clinical Warehouse due to the Joint Commission’s data being blinded as to whom the hospital and patient are:
  • Performance Measurement System Identifier – not part of the file, captured at the point the file is uploaded to The Joint Commission
  • Vendor Tracking ID – fictitious identifier generated by the measurement system to differentiate between individual patient records across their client hospitals
  • Admission Date
  • Discharge Date
  • Measure Set
• Transaction Processing: Data can be added, replaced, and deleted during the current reporting quarter using the Action-Code in the XML file. In order to replace or delete an existing file at The Joint Commission, the files must match on the unique key data elements as defined above.
• Measure Selection: Data that passes all edits and contains all data required to calculate the measures will be accepted as long as at least one hospital has selected the measure set for the reporting quarter with the performance measurement system that is submitting the data.
• Sample: All EOC records included in the sample, or if the hospital is not sampling the Initial Patient Population, must be transmitted to The Joint Commission. This is true regardless of whether or not any measure for the record calculates to a Measure Category Assignment = “X”.
• Data Elements Not Accepted by The Joint Commission: The following data elements may be transmitted to CMS, but cannot be transmitted to The Joint Commission because the data transmitted to The Joint Commission is anonymous. Files transmitted to The Joint Commission that contain the following data will be rejected:
  • Provider Identifier (Medicare Provider ID)
  • National Provider Identifier (NPI)
  • Healthcare Organization Identifier
  • Hospital Patient Identifier
  • Patient HIC #
  • First Name
  • Last Name
  • Race
  • Hispanic Ethnicity
  • Postal Code
• Data Elements Required by The Joint Commission That Are Not Required by CMS: In order to support the Joint Commission’s data quality analysis and continuous measure verification process the following data elements are required to be transmitted for each measure in the measure set.
  • Measure Category Assignment
  • Measurement Value
  • Predicted Value

• A fictitious identifier is generated by the measurement system to differentiate between individual patient records across their client hospitals because the Joint Commission’s data are blinded as to whom the hospital and patient are. The following data element is used to transmit this fictitious identifier.
  • Vendor Tracking ID

Aggregate Data

Aggregate hospital data is required to be submitted to The Joint Commission no less than on a quarterly basis.

• Technical Manual: Performance measurement systems will reference the applicable version of the ORYX Technical Implementation Guide for instructions and data element definitions that pertain to the transmission of aggregate data for both ORYX and national hospital quality measure data.
• Stratified national hospital quality measures: Although a stratified measure will often be referred to as a single measure (such as measure SCIP-Inf-1), the overall rate and the individual strata measures will actually be transmitted to The Joint Commission in the aggregate HCO-level data as a series of measures, using a number of pre-determined transmission ID numbers.
• Missing and Invalid Data: The following data elements are required for national hospital quality measures and must be included in the health care organization (HCO)-level data transmission file. These will not be used for traditional ORYX data. The data elements include:
  • Number of Cases With An Influenza Vaccination
  • Number of Rejected Cases
  • Number of Cases with UTD Allowable Values
  • ICD Population Size
  • Sample

Refer to the “HCO-Level Data Elements” and “Electronic Data Interchange” sections of the ORYX Technical Implementation Guide for a complete set of definitions, allowable values, and edits related to these data elements.

• Identifiers used to transmit aggregate national hospital quality measure data: The performance measure identifiers used to transmit aggregate HCO-level data to The Joint Commission are presented in this section. See Tables 1 to Table 6 that follow for the transmission identifiers used to transmit aggregate HCO-level national hospital quality measure data to The Joint Commission.
• ORYX data re-transmission: The Joint Commission acknowledges that it is appropriate to allow ORYX data to be updated. We are interested in assuring the best possible data quality, especially in light of public reporting. Toward that end, we routinely accept retransmission of up to seven quarters of aggregate national hospital quality (core) measures, as well as aggregate non-core measure data with each regularly scheduled transmission deadline, for the purposes of updating data for the ORYX Performance Measure Reports, national comparison group data, and the health care organization Quality Report postings. These retransmitted data may be inclusive of updated data previously submitted and/or data that may have been erroneously omitted.

Measurement systems are required to correct their recognized data integrity issues and retransmit up to seven quarters of updated aggregate national hospital quality (core) measures and aggregate non-core measure data (due to the rolling quarters of the ORYX Performance Measure Reports that display up to 24 months of data) by the next regularly scheduled quarterly transmission deadline. Retransmission of corrected aggregate data from issues emanating at the client health care organization-level is encouraged whenever feasible. It is the responsibility of the measurement system to notify their clients that updated data were retransmitted to The Joint Commission, and that the subsequent Quality Report posting and future ORYX Performance Measure Reports will reflect these data. It is important to note, these retransmitted data will refresh the following quarter’s ORYX Performance Measure Reports and Quality Report (core only), and update the national comparison group rates (core only).

Refer to the ORYX Performance Measurement System Agreement, ORYX Data Retransmission Process, for further details and associated fees that apply. Measurement system inquires related to the retransmission of ORYX data should be directed to oryxdq@jointcommission.org.

Information The Joint Commission Provides To Core Performance Measurement Systems

Risk Adjustment: The Joint Commission will provide core measurement systems with risk adjustment model information for the national hospital quality measures (AMI-9, PR-1, PR-2, and PR-3) that require risk adjustment. Measurement systems must apply the risk model information to their patient-level data and generate aggregate risk adjustment data for submission to The Joint Commission as a part of HCO-level data elements. Additional specifics include:

• Measurement systems will have access to current national hospital quality measure risk model information files through the Performance Measurement System Extranet Track (PET).
• Details related to the risk model information file, its usage by measurement systems, and a list of significant risk factors are provided in the ORYX Risk Adjustment Guide. This guide is available to the public on the Joint Commission’s website and, in addition, it is available to performance measurement systems via the Joint Commission’s extranet site for measurement systems (PET).
• National hospital quality measure risk models must not be used for any purposes other than calculating risk-adjusted data elements.
• For assistance with the national hospital quality measure risk model information, please contact the ORYX statistical support e-mail box at oryxstat@jointcommission.org.

National Comparison Group: The Joint Commission will provide core measurement systems participating in the ORYX national hospital quality measure initiative with national comparison group data. Measurement systems may use this information to prepare feedback reports for client organizations. Additional details in regard to this process include:

• Measurement systems will have access to national comparison group data through the Performance Measurement System Extranet Track (PET).
• Refer to the ORYX Data Quality Manual for the list of national comparison group data elements and related information.
• National ORYX comparison group data must not be used for any purposes other than creating national hospital quality measure feedback reports for client organizations.
• For assistance with the national hospital quality measure national comparison group, please contact the ORYX statistical support e-mail box at oryxstat@jointcommission.org.

Table 1 – Acute Myocardial Infarction Measures

Set Measure ID	Transmission ID	Start Date	End Date	Measure Short Name
AMI-1	14229	1 Jul 2002	ongoing	Aspirin at Arrival
AMI-2	14230	01 Jul 2002	Ongoing	Aspirin Prescribed at Discharge
AMI-3	14231	01 Jul 2002	Ongoing	ACEI or ARB for LVSD
AMI-4	14228	01 Jul 2002	Ongoing	Adult Smoking Cessation Advice/Counseling
AMI-5	14232	01 Jul 2002	Ongoing	Beta-Blocker Prescribed at Discharge
AMI-6	14234	01 Jul 2002	Ongoing	Beta-Blocker at Arrival
AMI-7	14226	01 Jul 2002	Ongoing	Median Time to Fibrinolysis
AMI-7a	14236	01 Jul 2004	Ongoing	Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
AMI-8	14227	01 Jul 2002	Ongoing	Median Time to Primary PCI
AMI-8a	14235	01 Jul 2004	Ongoing	Primary PCI Received Within 90 Minutes of Hospital Arrival
AMI-9	14233	01 Jul 2002	Ongoing	Inpatient Mortality
AMI-T1a				LDL Cholesterol Assessment (Optional Test Measure)
AMI-T2				Lipid-Lowering Therapy at Discharge (Optional Test Measure)

Table 2 – Heart Failure Measures

Set Measure ID	Transmission ID	Start Date	End Date	Measure Short Name
HF-1	14335	01 Jul 2002	Ongoing	Discharge Instructions
HF-2	14336	01 Jul 2002	Ongoing	Evaluation of LVS Function
HF-3	14339	01 Jul 2002	Ongoing	ACEI or ARB for LVSD
HF-4	14337	01 Jul 2002	Ongoing	Adult Smoking Cessation Advice/Counseling

Table 3 – Pneumonia Measures

Set Measure ID	Transmission ID	Start Date	End Date	Measure Short Name
PN-2	14442	01 Jul 2002	Ongoing	Pneumococcal Vaccination
PN-7	14451	01 Jul 2004	Ongoing	Influenza Vaccination
PN-3a	14452	01 Jul 2005	Ongoing	Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival
PN-3b	14453	01 Jan 2006	Ongoing	Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital
PN-4	14445	01 Jul 2002	Ongoing	Adult Smoking Cessation Advice/Counseling
PN-5	14444	01 Jul 2002	Ongoing	Antibiotic Timing (Median)
PN-5a				Initial Antibiotic Received Within 8 Hours of Hospital Arrival - RETIRED
PN-6b	14450	01 Jul 2004	Ongoing	Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients – Non ICU Patients
PN-5b	14448	01 Jul 2004	Ongoing	Initial Antibiotic Received Within 4 Hours of Hospital Arrival
PN-5c	14454	01 Apr 2007	Ongoing	Initial Antibiotic Received Within 6 Hours of Hospital Arrival (NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE)
PN-6				Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients
PN-6a	14449	01 Jul 2004	Ongoing	Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients – Intensive Care Unit (ICU) Patients

Table 4 – Pregnancy and Related Conditions Measures

Set Measure ID	Transmission ID	Start Date	End Date	Measure Short Name
PR-1	14547	01 Jul 2002	Ongoing	VBAC
PR-2	14548	01 Jul 2002	Ongoing	Inpatient Neonatal Mortality
PR-3	14555	01 Jul 2002	Ongoing	Third or Fourth Degree Laceration

Table 5 – Surgical Care Improvement Project Measures

Set Measure ID	Transmission ID	Start Date	End Date	Measure Short Name
SCIP-Inf-1a	14657	01 Jul 2004	Ongoing	Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Overall Rate
SCIP-Inf-1b	14658	01 Jul 2004	Ongoing	Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - CABG
SCIP-Inf-1c	14659	01 Jul 2004	Ongoing	Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Other Cardiac Surgery
SCIP-Inf-1d	14660	01 Jul 2004	Ongoing	Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hip Arthroplasty
SCIP-Inf-1e	14661	01 Jul 2004	Ongoing	Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Knee Arthroplasty
SCIP-Inf-1f	14662	01 Jul 2004	Ongoing	Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Colon Surgery
SCIP-Inf-1g	14663	01 Jul 2004	Ongoing	Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hysterectomy
SCIP-Inf-1h	14664	01 Jul 2004	Ongoing	Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Vascular Surgery
SCIP-Inf-2a	14666	01 Jul 2004	Ongoing	Prophylactic Antibiotic Selection for Surgical Patients - Overall Rate
SCIP-Inf-2b	14667	01 Jul 2004	Ongoing	Prophylactic Antibiotic Selection for Surgical Patients - CABG
SCIP-Inf-2c	14668	01 Jul 2004	Ongoing	Prophylactic Antibiotic Selection for Surgical Patients - Other Cardiac Surgery
SCIP-Inf-2d	14669	01 Jul 2004	Ongoing	Prophylactic Antibiotic Selection for Surgical Patients - Hip Arthroplasty
SCIP-Inf-2e	14670	01 Jul 2004	Ongoing	Prophylactic Antibiotic Selection for Surgical Patients - Knee Arthroplasty
SCIP-Inf-2f	14671	01 Jul 2004	Ongoing	Prophylactic Antibiotic Selection for Surgical Patients - Colon Surgery
SCIP-Inf-2g	14672	01 Jul 2004	Ongoing	Prophylactic Antibiotic Selection for Surgical Patients - Hysterectomy
SCIP-Inf-2h	14673	01 Jul 2004	Ongoing	Prophylactic Antibiotic Selection for Surgical Patients - Vascular Surgery
SCIP-Inf-3a	14675	01 Jul 2004	Ongoing	Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Overall Rate
SCIP-Inf-3b	14676	01 Jul 2004	Ongoing	Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery End Time – CABG
SCIP-Inf-3c	14677	01 Jul 2004	Ongoing	Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery End Time - Other Cardiac Surgery
SCIP-Inf-3d	14678	01 Jul 2004	Ongoing	Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Hip Arthroplasty
SCIP-Inf-3e	14679	01 Jul 2004	Ongoing	Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Knee Arthroplasty
SCIP-Inf-3f	14680	01 Jul 2004	Ongoing	Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Colon Surgery
SCIP-Inf-3g	14681	01 Jul 2004	Ongoing	Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time – Hysterectomy
SCIP-Inf-3h	14682	01 Jul 2004	Ongoing	Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Vascular Surgery
SCIP-Inf-4	14684	01 Jul 2006	Ongoing	Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose
SCIP-Inf-6	14685	01 Jul 2006	Ongoing	Surgery Patients with Appropriate Hair Removal
SCIP-Inf-7	14686	01 Jul 2006	Ongoing	Colorectal Surgery Patients with Immediate Postoperative Normothermia
SCIP-Card-2	14688	01 Oct 2006	Ongoing	Surgery Patients on Beta-Blocker Therapy Prior to Admission Who Received a Beta-Blocker During the Perioperative Period
SCIP-venous-thromboembolism-1	14690	01 Oct 2006	Ongoing	Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
SCIP-venous-thromboembolism-2	14691	01 Oct 2006	Ongoing	Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery
SCIP-Inf-1				Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
SCIP-Inf-2				Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3				Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time

Table 6 – Children’s Asthma Care Measures

Set Measure ID	Transmission ID	Start Date	End Date	Measure Short Name
CAC-1a	14900	01 Apr 2007	Ongoing	Relievers for Inpatient Asthma (age 2 through 17 years) – Overall Rate
CAC-1b	14901	01 Apr 2007	Ongoing	Relievers for Inpatient Asthma (age 2 through 4 years)
CAC-1c	14902	01 Apr 2007	Ongoing	Relievers for Inpatient Asthma (age 5 through 12 years)
CAC-1d	14903	01 Apr 2007	Ongoing	Relievers for Inpatient Asthma (age 13 through 17 years)
CAC-2a	14905	01 Apr 2007	Ongoing	Systemic Corticosteroids for Inpatient Asthma (age 2 through 17 years) – Overall Rate
CAC-2b	14906	01 Apr 2007	Ongoing	Systemic Corticosteroids for Inpatient Asthma (age 2 through 4 years)
CAC-2c	14907	01 Apr 2007	Ongoing	Systemic Corticosteroids for Inpatient Asthma (age 5 through 12 years)
CAC-2d	14908	01 Apr 2007	Ongoing	Systemic Corticosteroids for Inpatient Asthma (age 13 through 17 years)
CAC-3	14910	01 Apr 2007	Ongoing	Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
CAC-2				Systemic Corticosteroids for Inpatient Asthma
CAC-1				Relievers for Inpatient Asthma

CMS National Hospital Quality Measure Data Transmission

Overview

Data collected for Centers for Medicare & Medicaid Services (CMS) is transmitted to the QIO Clinical Warehouse, CMS’s central repository for clinical data. All data submitted is required to meet transmission requirements. The file layout requirements are included in the sections that follow.

Hospitals currently submit patient-level clinical data to the QIO Clinical Warehouse, and hospitals submit the Medicare and non-Medicare Initial Patient Population Size (by measure set or stratum for SCIP) and designation of sampling for the Medicare and non-Medicare sample size. Please refer to the Hospital Clinical Data XML File Layout and/or the Hospital Initial Patient Population Data XML File Layout for specific national hospital quality measure data transmission requirements. Additionally, please refer to the QualityNet website for the current annual Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) submission requirements for patient-level clinical data and Initial Patient Population data.

• Download Hospital Clinical Data XML File Layout (MS Excel)

• Download ICD Population XML File Layout (MS Excel)

Submission of Hospital Clinical Data

Hospital Clinical Data is submitted to the QIO Clinical Warehouse on a quarterly submission schedule. All clinical data submitted to the QIO Clinical Warehouse must adhere to the Hospital Clinical Data XML File Layout specifications provided later in the transmission section. Each case must have a separate XML file. For example, if you have 12 records that you have abstracted, you must have 12 separate XML files. If you have abstracted more than one Measure Set for a patient stay, then a separate XML file must be created for each Measure Set. Each Measure Set can only be abstracted once for the same medical record.

Submission of Hospital Initial Patient Population Data

CMS collects Initial Patient Population Size and declaration of sampling, by Measure Set on a quarterly basis. For hospitals submitting the Hospital Initial Patient Population Data, information may be submitted via an XML file to the QIO Clinical Warehouse. All Initial Patient Population data submitted to the QIO Clinical Warehouse must adhere to the Hospital Initial Patient Population Data XML File Layout specifications provided later in the transmission section. Each file may contain data for only one provider.

Additional guidelines related to the submission of Hospital Clinical Data and Hospital Initial Patient Population Data are outlined below.

CMS and Joint Commission Guidelines for Submission of Data

Overview

The below guidelines are for the submission of Hospital Clinical Data and Hospital Initial Patient Population Data to both CMS and The Joint Commission. Additionally, for the current QIO Clinical Warehouse Edits Documents (Error Messages and Measure Messages) please refer to the QualityNet website. For the Joint Commission’s Hospital Clinical Data Edit and Algorithm Error Messages, please refer to the Joint Commission’s extranet for measurement systems (PET).

Abstraction Software Skip Logic and Missing Data

Skip logic allows hospitals and vendors to minimize abstraction burden by using vendor software edit logic to bypass abstraction of data elements not utilized in the measure algorithm. However, these bypassed elements also negatively impact data quality and the hospital’s CMS chart audit validation results when elements are incorrectly abstracted and subsequent data elements are bypassed and left blank.

The use of skip logic by hospitals and ORYX vendors is optional and not required by CMS and The Joint Commission. Hospitals should be aware the potential impact of skip logic on data quality, abstraction burden, and CMS chart audit validation scores. Vendors and hospitals utilizing skip logic should closely monitor the accuracy rate of abstracted data elements, particularly data elements placed higher in the algorithm flow (e.g., Comfort Measures data element).

Historically, CMS chart audit validation results have been used in previous payment years as one of many requirements in the Reporting Hospital Quality for Annual Payment Update (RHQDAPU) program. Please refer to the Federal Register and the QualityNet website for the current payment year’s proposed and final requirements for acute care Inpatient Prospective Payment System (IPPS) hospitals.

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Related Topics

Related Topics
d. Missing and Invalid Data Chapter
a. Table of Contents
j1. Transmission Alphabetical Data Dictionary
j. National Hospital Quality Measure Data Transmission
j2. Joint Commission and CMS Data Processing Flow