TJC, CMS release new specifications manual
TJC, CMS release new specifications manual
Two core measures added
In April, The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) put out an updated measures specifications manual that introduced two new core measures.
The manual, says Jennifer Cowel, RN, MHSA, with Patton Healthcare Consulting in Glendale, AZ, seeks to answer questions such as:
- How do you define each data element?
- What are the risk adjustment factors?
- How do you collect it?
"And that's obviously important because if people don't understand what the specific measures are, what the data elements are, what is considered a record that can and should be abstracted, what is a record that does not fall in a parameter for this specific measure, hospitals can totally screw themselves on the data," she says.
Three measure sets added
What's most important to the quality manager, with the release of the specifications manual, was the release of three new measure sets: venous thromboembolism (VTE), stroke, and emergency department (ED). While the ED measure set, set forth by CMS, is information-only and will not be used for reporting, the other two are now added to the list of core measures from which hospitals must pick four to report on to The Joint Commission. The VTE and stroke measures do not require reporting by hospitals from CMS in 2010.
Asked if the data elements and requirements overall are going to be much more work for the QI director, Brett Bennett, senior vice president, Quality Indicator Project, Maryland Hospital Association, says, "We think so. And frankly, we don't see that subsiding in the future."
He advises QI managers looking at the two new measure sets "to take a step back and evaluate from where those data are going to be gathered, because if processes are not in place then they'll need to be established in order to properly collect that information, particularly around stroke and some of the other measure sets where the population is fairly pervasive."
Bennett recounts that he was recently talking to a group of quality directors from hospitals that were submitting data to a stroke registry but the quality department didn't have much involvement in the data collection, which was handled mainly through the neurology department. The quality directors, he says, "recognized it was going to be important for them to connect themselves with that neurology department and either instruct the physician assistants, who were collecting information, on how The Joint Commission needed to see [the data] in the future or they were going to simpy have to take on that responsibility themselves."
The specifications manual can help by identifying where the data being asked for would be located. Bennett says it elucidates, "why is the measure important, what is its numerator and denominator, what kind of patients get included and excluded, and what's the literature base behind the individual measure." Critical stuff for the QI manager, he says.
Study the data dictionary
"I think that the most important take-away that I would like to share with people about use of the specifications manual is that they have to use it," says Ann Watt, associate director in the division of quality measurement and research at The Joint Commission.
"They have to look and know those data elements definitions, they have to abstract data according to those data element definitions, and they cannot infer based on their clinical knowledge what they think that the answer should be. We write those specifications to the level of somebody who has no clinical knowledge whatsoever, and we intend that they be taken very literally. We do this in order to ensure interrater reliability. One of the biggest problems occurs when you have somebody who puts on their clinical hat and says, 'Ah, well I know that this is why he did this,' the doctor generally, 'so I'm going to answer the question this way even though that is not what the data element specifications say.' That's like death to quality improvement."
She stresses familiarizing yourself with the data dictionary. And Debra Bell, RN, MS, CNA, director, performance improvement at Wheeling Hospital in Wheeling, WV, agrees. "It's helpful especially when you are trying to explain data to your physician group or to another group that you need to buy in to help make sure you're explaining things correctly."
The data dictionary helps identify your population for data collection, who should be included and who should be excluded, and where the data can be found. The latter, Bell says, "is really helpful."
Bell works hand in hand with the case management department at Wheeling and says that has worked well. "[T]he case managers who are on the floors and communicating with the physicians on a regular basis can check the charts and make sure the documentation that needs to be there is there. And then that makes it easier on the back end when we're doing the chart reviews." The case managers also share data at medical staff meetings and, beyond educating physicians, they can let them know where they stand on core measures and areas that need improvement.
Cowel says she sees a lot of hospitals in her practice that need to learn a lot when it comes to core measure specifications, and she says, "they oftentimes give a goal of abstracting data for these measure sets to a clerical-level person who doesn't get it and doesn't care all that much and hasn't been trained."
Bell has an RN handle abstraction. "As far as abstraction, I think you have to have people who are compulsive. The person who is in charge of my data abstraction... she makes sure she knows the rules, that she communicates the rules, that we follow the rules."
Why VTE and stroke?
Loeb says a number of factors led to the addition of the VTE and stroke measure sets. As far as VTE, Loeb references the Sept. 15, 2008, release of the surgeon general's call to action on deep vein thrombosis and pulmonary embolism. VTE, Loeb says, "is underrecognized as a problem. It is an area in which there are significant numbers of, and I'm going to use a strong word here, needless deaths, because we know a fair amount about the prevalence. We know a fair amount about how to prevent VTE. There's a lot of anecdotal evidence in the literature that a lot of modalities are being underutilized."
Besides being highlighted by the surgeon general, Loeb says VTE also is getting a lot of attention from the Department of Health and Human Services "vis a vis CMS" as well as from the Agency for Healthcare Research and Quality.
And with the stroke population, he says, "here, too, is an area in which we know there is significant morbidity and mortality; not in every case but in some cases, timing and appropriate therapy, particularly if it's an ischemic stroke, can make a huge difference."
The Joint Commission, he says, worked with other organizations on standardizing the stroke set measures, working with the Centers for Disease Control and Prevention's Coverdell Registry for stroke (for which many hospitals already are submitting data, he adds), as well as the American Stroke Association and Get with the Guidelines program for stroke. And as of Jan. 1, the core measure set will be synonymous with the standards required for hospitals looking for disease-care specific certification in stroke by TJC.
Loeb says The Joint Commission, as an accrediting body, plays a "very unique role" and is able to "shine the light on things" as it has with its new measures on which "there was a confluence of national interest, increasing data to suggest there's significant variability in performance on the part of health care organizations, and perhaps most importantly an opportunity to improve that."
Cowel says The Joint Commission is not growing core measures "themselves anymore," the way it might have in the past. She says The Joint Commission has come closer in line with other national players such as NQF and CMS, and become "part of the national scene, and when the national scene of quality organizations come up with a new measure set [The Joint Commission] will adopt it as one of the core measure sets you can use. And that is good for the industry, it's good for the hospitals."
Give new measure sets a try
Bennett says internally the Maryland Hospital Association advises its clients that "even if a measure set is not required, to begin data collection for those measures sets as early as possible for a couple of reasons. One is so they can establish a baseline and understand their performance in that area, which is by design what collecting this information should be used for anyway. But also to get ahead of the curve so that they're collecting information and understanding where they may have some challenges in gathering the data prior to going 'live' in a pressure-filled kind of situation."
(Editor's note: You can access the latest specifications manual, version 3.0, at www.qualitynet.org. Select "Hospitals - Inpatient" on the left of the top navigation bar and select "Specifications Manual" from the drop down menu.)In April, The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) put out an updated measures specifications manual that introduced two new core measures.
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