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Using The Manual
Version 2010B

Using the Specifications Manual for National Hospital Inpatient Quality Measures

The Specifications Manual for National Hospital Inpatient Quality Measures is periodically updated for a specific data collection time period (i.e., based on hospital discharge dates) with a Version number and Effective Discharges date ( e.g., Version 2.3, Effective 10/01/2007 Discharges) associated with each applicable manual. Over time, it may be necessary to present more than one version of a specific data collection time period due to corrections or clarifications based on ongoing alignment discussion between the Centers for Medicare & Medicaid Services and the Joint Commission. When more than one version of the manual is posted for a specific discharge period, an alpha character is added following the version number to identify there were corrections or clarifications made to the previous release and this would identify the most up-to-date information.

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 hospital national quality measures. The sections of this manual are interrelated and are most useful when considered together.

The initial selection of medical records, intended for data abstraction of the National Hospital Quality Measures, must meet the following criteria:

  • Acute inpatient
  • All payor sources
For topic specific Initial Patient Populations, refer to Section 2 (“Measurement Information”) and Section 4 (“Population and Sampling Specifications”) of this manual.

Section 1: Introduction to the Data Dictionary

The Data Dictionary describes the patient-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 any of the selected Initial Patient Populations and those data elements needed for a specific measure set.

Section 2 - Measurement Information

The measure information section is divided by measure sets [i.e., Acute Myocardial Infarction (AMI), Children’s Asthma Care (CAC), Heart Failure (HF), Pneumonia (PN), Surgical Care Improvement Project (SCIP) and Pregnancy and Related Conditions (PR) ]. At the beginning of each set is a listing of the measures comprising the set, including the set measure identification number (alphanumeric number to identify a measure within a set) and the measure short name. For example, in the heart failure measure (HF) set, the measure that addresses HF patients receiving discharge instructions is listed as: HF-1 and measure short name: Discharge instructions. This is followed by a data element list for the measure set, including the general data elements, algorithm output data elements, and the specific measure set data elements. Next is a document that describes the Initial Patient Population 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 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. For risk adjusted measures, a separate algorithm determines if risk factor data elements are present.

Section 3: Missing and Invalid Data

This section addresses CMS’s and 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 QIO Clinical Warehouse and 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.

Section 4: Population and Sampling Specifications

Sampling is an available option for all national hospital 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 transmission of Initial Patient Population and sample data elements to the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse.

Section 5 – Reserved for Future Use

Section 6 – Reserved for Future Use

Section 7 – Reserved for Future Use

Section 8 – National Hospital Quality Measure Verification Process (Joint Commission Performance Measurement Systems Only)

This section has been moved to the ORYX Data Quality Manual and is available to performance measurement systems via the Joint Commission’s extranet site for measurement systems (PET).

Section 9: National Hospital Quality Measure Data Transmission

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 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. The CMS Transmission section provides the data standards required for submission to the QIO Clinical Warehouse. The Guidelines for Submission of Data include 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 evaluate the national hospital quality measures. In addition, it highlights the processing differences between the two warehouses.

Section 10 – CMS Risk-Adjusted 30-Day Mortality Measures

This section of the manual provides an overview and the Measure Information Forms for the CMS risk-adjusted 30-day mortality measures.

Appendix A - ICD-9-CM 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-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. This includes 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.

Appendix B – Reserved for Future Use

Appendix C - Medication Tables

Several of the national quality measures address the use and timing of certain medications. This Appendix contains tables with the specific names that may be associated with medication categories (e.g., trade names). For example, angiotensin converting enzyme inhibitors (ACEI) may also be documented as Captopril, Capozide, Vasotec, etc. 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. Discrepancies must be reported. See the Resource Section of this manual for contact information.

Appendix D - Glossary of Terms

Appendix E: Overview of Measure Information Form and Flowchart Formats for Collected Measures

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 F – Reserved for Future Use

Appendix G - Resources

This appendix contains available resources to those using this manual.

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. For example, the LVSF Assessment Inclusion Table is used to supplement abstraction guidelines for the data element LVF Assessment.

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