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Appendix CTJC
Version 2012A

Appendix C

General Glossary of Terms

AMA (Against Medical Advice) When a patient checks himself out of a hospital against the advice of his doctor.

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

acute hemorrhagic stroke A non-traumatic intracerebral hemorrhage, subarachnoid hemorrhage or hemorrhagic infarction.

acute ischemic stroke A measurable neurological deficit of sudden onset, presumed secondary to focal cerebral ischemia, and not otherwise attributable to intracerebral hemorrhage (ICH) or another disease process. Cerebrovascular disorder caused by deprivation of blood flow to an area of the brain, generally as a result of thrombosis, embolism, or reduced blood pressure.

acute myocardial infarction (AMI) Death of heart muscle resulting from insufficient blood supply to the heart.

administrative/billing data (data source) Administrative data are patient-identifiable data used for administrative, regulatory, and payment (financial) purposes. Administrative data that generally reflect 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 admission source, length of stay, charges, discharge status; and ICD-9-CM diagnostic and procedure codes). Namely, the Uniform Hospital Discharge Data Set and the Uniform Bill of the Health Care Financing Administration (UB-04) provides specifications for the abstraction of administrative/billing data.

Agency for Healthcare Research and Quality (AHRQ) The Agency for Healthcare Research and Quality (AHRQ) is the health services research arm of the U.S. Department of Health and Human Services (HHS), complementing the biomedical research mission of its sister agency, the National Institutes of Health. AHRQ is a home to research centers that specialize in major areas of health care research such as quality improvement and patient safety, outcomes and effectiveness of care, clinical practice and technology assessment, and health care organization and delivery systems.

aftercare (see next level of care) Inpatient or outpatient care that the patient will receive after discharge from the hospital.

aggregate (hospital data) Aggregate data elements derived for a specific hospital from the results of each measure's algorithm over a given time period (e.g., monthly, quarterly). These data are transmitted to The Joint Commission by ORYX® Vendors.

aggregate risk-adjusted data elements Aggregate data elements derived from episode of care (EOC) records that result from the application of risk adjustment models by ORYX® Vendors for transmission to The Joint Commission.

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.

angioplasty Reconstruction of blood vessels damaged by disease or injury.

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

antenatal steroids Steroids given before birth.

antithrombotic therapy Pharmacologic agents (oral or parenteral) preventing or interfering with the formation of a thrombus or blood coagulation.

atherosclerosis Common disorder characterized by yellowish plaques of cholesterol, other lipids, and cellular debris in the inner layers of the walls of arteries.

atrial fibrillation Cardiac arrhythmia characterized by disorganized electrical activity in the atria accompanied by an irregular ventricular response that is usually rapid. The atria quiver instead of pumping in an organized fashion, resulting in compromised ventricular filling and reduced stroke volume. Stasis of left atrial flow increases the risk of stroke.

atrial flutter Type of atrial tachycardia characterized by contraction rates between 230/min and 380/min.

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.

calculation model A description of the steps or statistical calculations (computations) used to derive the numerator and denominator or continuous variable values required for a measure. Measure Information Forms in this manual will include either an algorithm or calculation model.

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.

children’s asthma care (CAC) Asthma is defined as a lung disorder marked by breathing difficulty, wheezing, or coughing. For purposes of this measure set, the population is defined as children equal or greater than 2 through 17 years of age.

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. (ORYX® Vendors 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 hospital 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) A facility that meets the following criteria may be designated by CMS as a CAH:

  • Is located in a State that has established with CMS a Medicare rural hospital flexibility program; and
  • Has been designated by the State as a CAH; and
  • Is currently participating in Medicare as a rural public, non-profit or for-profit hospital; or was a participating hospital that ceased operation during the 10-year period from November 29, 1989 to November 29, 1999; or is a health clinic or health center that was downsized from a hospital; and
  • Is located in a rural area or is treated as rural; and Is 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); and
  • Maintains no more than 25 inpatient beds; and
  • Maintains an annual average length of stay of 96 hours per patient for acute inpatient care; and
  • Complies with all CAH Conditions of Participation, including the requirements to make available 24-hour emergency care services 7 days per week.
  • A CAH may also be granted “swing-bed” approval to provide post-hospital Skilled Nursing Facility-level care in its inpatient beds. In the case of hospice care, a hospice may contract with a CAH to provide the Medicare hospice hospital benefit. Reimbursement from Medicare is made to the hospice. The CAH may dedicate beds to the hospice, but the beds must be counted toward the 25-bed maximum. However, the hospice patient is not included in the calculation of the 96-hour annual average length of stay. The hospice patient can be admitted to the CAH for any care involved in their treatment plan or for respite care. The CAH negotiates reimbursement through an agreement with the hospice. In addition to the 25 inpatient CAH beds, a CAH may also operate a psychiatric and/or a rehabilitation distinct part unit of up to 10 beds each. These units must comply with the Hospital Conditions of Participation.

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 their selected ORYX® Vendor, and the vendor 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.

elective carotid endarterectomy Surgical procedure performed by choice, involving excision of atheromatous segments of the endothelium and tunica media of the carotid artery, leaving a smooth tissue lining and facilitating blood flow through the vessel; surgery done to prevent stroke.

elective carotid intervention Surgery (i.e., carotid endarterectomy) and other procedures (e.g., carotid angioplasty, stenting) involving the carotid artery, performed due to the patient’s choice.

elective delivery Delivery of a newborn(s) when the mother was not in active labor or presented with spontaneous ruptured membranes prior to medical induction and/or cesarean section.

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.

elopement When a patient wanders away, walks away, runs away, escapes, or otherwise leaves the hospital unsupervised, unnoticed, and/or prior to their scheduled discharge.

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 TM” is the name given to the Joint Commission’s extranet site.

event An occurrence of physical restraint or seclusion. Events that occur during the patient's stay do not define new episodes of care.

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, character, or alphanumeric; and the frequency with which the data element occurs.

general data elements Those data elements that have wide application and are collected for every patient that is included in any measure population.

global Global is an umbrella term for all measure sets that share the same Initial Patient Population definition.

health care-associated infection A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s). There must be no evidence that the infection was present or incubating at the time of admission to the care setting.

health care organization (HCO) The business entity which is participating in an ORYX Vendor (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 health care organization on a performance measure. This data is transmitted to The Joint Commission by the hospital’s ORYX Vendor.

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.

hospital-based inpatient psychiatric services (HBIPS) The Hospital-Based Inpatient Psychiatric Services (HBIPS) is a national quality partnership of organizations focused on improving quality and performance in impatient psychiatric settings through performance measurement utilizing 5 process measures in 3 separate domains (assessment, patient safety, continuity/transition of care).

Hospital Inpatient Quality Reporting Program The Hospital Inpatient Quality Reporting Program, formerly known as Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program, 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 Hospital Inpatient Quality Reporting Program initiative is available to consumers on the Hospital Compare website.

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

ICD-9-CM codes A two-part classification system in current use for coding patient medical information used in abstracting systems and for classifying patients into diagnosis-related groups (DRGs). The first part is a comprehensive list of diseases with corresponding codes compatible with the World Health Organization’s list of disease codes. The second part contains procedure codes independent of the disease codes.

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.

inpatient prospective payment system (IPPS) rule A prospective payment system (PPS) under Medicare for hospital acute inpatient services. Hospitals contract with Medicare to furnish acute inpatient care and are reimbursed through pre-determined payment on a per discharge or per case basis for Medicare beneficiaries with inpatient stays.

inpatient psychiatric services Inpatient psychiatric services include care provided to a patient for a mental disorder while hospitalized in a psychiatric unit of an acute care hospital or a free-standing psychiatric hospital. Services rendered to outpatients or “day treatment” patients are not considered inpatient psychiatric services.

intermittent pneumatic compression device Device that uses sequential and/or intermittent compression to counteract blood flow stasis by increasing peak flow velocity. As a result, less blood is allowed to pool in veins thus decreasing chances for thrombus formation. In addition compression has an anticlotting effect by increasing fibrolytic activity which in turn stimulates the release of plasminogen activator. These two physiological effects, in combination with the mechanical movement of fluid in a proximal direction make the sequential devices effective in preventing and treating VTE.

intracerebral hemorrhage (ICH) Non-traumatic abrupt onset of headache or altered level of consciousness and/or focal neurological deficit that is associated with a focal collection of blood within the brain parenchyma on CT scan and is not due to trauma or hemorrhagic conversion of a cerebral infarction.

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.

IV thrombolytic therapy Intravenous administration of a thrombolytic agent, such as tissue plasminogen activator (TPA), to dissolve an arterial clot.

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

leave day An authorized or unauthorized absence from a facility, excluding discharges, during which the patient is absent from the facility at the time of the daily census and is not under the direct supervision of facility staff while absent.

low-density lipoprotein (LDL) Plasma protein provided by the liver, carrying relatively more cholesterol and triglycerides than protein. The high cholesterol content may account for its greater atherogenic potential. Also known as “bad cholesterol”.

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 data elements Data elements used by one specific measure or several measures in two or more measure sets, such as Clinical Trial.

measure information form Tool to provide specific clinical and technical information on a measure. The information contained includes: measure set, performance measure name, description, rationale, type of measure, improvement noted as, numerator/ denominator/continuous variable statements, included populations, excluded populations, data elements, risk adjustment, data collection approach, data accuracy, measure analysis suggestions, sampling, data reported as, and selected references.

measure of performance See performance measure.

measure-specific data elements Data elements used by one specific measure or several measures in one specific measure set, such as Infection Prior to Anesthesia in the SCIP measures.

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 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).

multiple antipsychotic medications Antipsychotic medications are drugs prescribed to treat certain mental disorders; if two or more of these medications are routinely administered or prescribed this is considered multiple antipsychotic medications.

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 intensive care unit (NICU) A hospital unit organized with personnel and equipment to provide continuous life support and comprehensive care for extremely high-risk newborn infants and those with complex and critical illness.

next level of care (see aftercare) Inpatient or outpatient care that the patient will receive after discharge from the hospital.

non-core measure A performance measure defined by the ORYX Vendor that has undergone review against Joint Commission established measure criteria and has been accepted for use in the ORYX initiative.

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.

ORYX® vendor 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. ORYX Vendors must be able to generate internal comparisons of organization performance over time, and external comparisons of performance among participating organizations at comparable times.

outpatient prospective payment system (OPPS) Rule A prospective payment system (PPS) under Medicare for hospital outpatient services, certain Part B services furnished to hospital inpatients that have no Part A coverage, and partial hospitalization services furnished by community mental health centers. All services paid under the PPS are classified into groups called Ambulatory Payment Classifications or APCs. A payment rate is established for each APC. Depending on the services provided, hospitals may be paid for more than one APC for an encounter.

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

parity The state of having given birth to an infant or infants, weighing 500gm or more, alive or dead.

paroxysmal Occurring as sudden or periodic attacks or recurrences of symptoms of a disease; exacerbation.

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. Refer to process measure and the outcome measure in Appendix D.

performance measurement system’s extranet track (PET) An electronic information and message center available to ORYX Vendors. Access to the Internet and a browser are necessary to connect to PET. Access to PET is available by clicking on the “Joint Commission Connect ™” button on the Joint Commission’s home page (www.jointcommission.org).

perinatal care (PC) The care and management of the fetus and newborn infant in the perinatal period before, during, and after delivery.

physical restraint A physical restraint is any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely when it is used as a restriction to manage a patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition.

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).

post discharge continuing care plan Communication from the hospital to the next level of care provider after a patient is discharged from the hospital. The plan must contain the reason for hospitalization, main diagnosis at discharge, a list of medications at discharge, and recommendations for the next level of care.

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.

P.R.N. Abbreviation for pro re nata, Latin term for "as needed".

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.

process measure A measure which focuses on a process which leads to a certain outcome, meaning that a scientific basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome.

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).

protected (personal) health information (PHI) A subset of health information, including demographics, that identifies the individual or for which there is a reasonable basis to believe that it can be used to identify the individual.

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 Derived by dividing the numerator (e.g., cases that meet the criterion for good or poor care) by the denominator (e.g., all cases to which the criterion applies) within a given time frame. In other words, the numerator is a subset of the denominator.

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 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.

routinely scheduled medications Medications prescribed to be taken regularly after discharge from the hospital.

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. Possible approaches to sampling include simple random sampling, cluster sampling, systematic sampling and judgment sampling.

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. For measure set specific "Sample Size Requirements" refer to Measure Information section.

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).

seclusion Seclusion is the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving.

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.

statin A class of pharmaceutical agents that modify LDL-cholesterol by blocking the action of an enzyme in the liver which is needed to synthesize cholesterol, thereby decreasing the level of cholesterol circulating in the blood; HMG-CoA reductase inhibitors.

stent Rod or threadlike device for supporting tubular structures during surgical anastamosis or for holding arteries open during percutaneous angioplasty.

strata See stratified measure.

stratification A form of risk adjustment which involves classifying data into subgroups 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 subgroups to assist in analysis and interpretation. The overall or un-stratified measure evaluates all subgroups together. The stratified measure consists of a subset of the overall measure. For example, surgical patients who received a prophylactic antibiotic within one hour prior to surgical incision can be reported as all surgical patients who received the prophylactic antibiotic within one hour prior to surgical incision; however, the stratified measure(s) for SCIP-Inf-1 could be reported by specific allowable values for the data element Infection Procedure of Interest, such as 1 – CABG (SCIP-Inf-1b) or 2 – Other Cardiac Surgery (SCIP-Inf-1c).

stratum See stratified measure.

stroke (STK) See definitions for acute ischemic stroke and acute hemorrhagic stroke.

subarachnoid hemorrhage (SAH) Non-traumatic abrupt onset of headache or altered level of consciousness that is associated with blood in the subarachnoid space on CT or a clinical history and exam consistent with SAH (sudden onset of severe headache or altered level of consciousness) with xanthochromia and many red blood cells in the cerebrospinal fluid.

sub-population A population that is part of a larger population. For example, the measure set Perinatal Care evaluates the obstetrical population in the hospital. This measure set is broken into two distinct sub-populations, mothers (PC-01, PC-02 and PC-33) and newborns (PC-04 and PC-05).

subset measure(s) A subset measure contains overlapping sets of patients. For example, the patients in the TOB-2a measure are a subset of those in the TOB-2 measure, i.e., the two measures have overlapping populations. This is distinctly different from measures that contain mutually exclusive sets of patients such as seen in the pneumonia measure set. For PN-6, the ICU patients are entirely separate from the non-ICU patients.

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 ten 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.

thrombolytic therapy See fibrinolytic therapy

time last known well Time at which the patient was last known to be without the signs and symptoms of the current stroke or at his or her prior baseline. Variation may exist if the signs and symptoms are not witnessed.

time-out The restriction of a patient for any period of time to a designated area from which the patient is not physically prevented from leaving and for the purpose of providing the patient an opportunity to regain self-control.

tissue plasminogen activator (TPA) Clot-dissolving substance produced naturally by cells in the walls of blood vessels, and also manufactured synthetically. TPA activates plasminogen to dissolve clots and is used therapeutically to open occluded arteries.

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.

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.qualitynet.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) A term that includes deep vein thrombosis and/or pulmonary embolism.

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

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.

Appendix CTJC
Specifications Manual for Joint Commission National Quality Measures (v2012A)
Discharges 01-01-12 (1Q12) through 06-30-12 (2Q12)