Post on 02-Jan-2016
description
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Library of Measures and Data Validation as
Required by Joint Commission International
Zakaria Zaki Al Attal
PhD, CPHQ
JCI consultant
Zalattal@jcrinc.com
Obadah10@hotmail.com
00971558818777
1
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
What is the JCI Library of Measures?
The Library of Measures consists of a list of10
disease specific population groups identified as
measure sets.
Each measure set consists of at least 2 to 8
process and/or outcome measures. A total of 36
2
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
International Library of Measures-
Measure Sets
1) Acute Myocardial Infarction (AMI) 6
2) Heart Failure (HF) 3
3) Stroke (STK) 4
4) Children’s Asthma Care (CAC) 2
5) Hospital-Based Inpatient Psychiatric Service (HBIPS) 2
6) Nursing-Sensitive Care (NSC) 3
7) Perinatal Care (PC) 3
8) Pneumonia (PN) 3
9) Surgical Care Improvement Project (SCIP) 8
10)Venous Thromboembolism (VTE) 2
3
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
4
122, 39%
191, 61%
JCI Accredited Hospitals (313) Respond to Library of Measures Survey
Survey Completed Survey Not Completed
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
5
46, 6% 37, 5%
37, 5%
70, 9%
44, 6%
75, 10%
439, 59%
International Hospitals Selections of Library Measures (36 measures) Top 6 Measures Selected to Date
I-AMI-1 ASA on arrival
I-AMI-2 ASA on discharge
NSC-2 Pressure ulcers
I-NSC-4 All falls
I-NSC-5 Falls with injuries
I-SCIP-1 Antibiotics within 1 hr.
Other
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Measurement Requirements in Standards
QPS.3.1 Standard, Measurable Element (ME) 2,
requires JCI accredited hospitals to select at least 5 of 36
measures from the Library of Measures.
Hospitals may select all 5 measures from one measure
set, or a total of 5 measures from different measure sets.
6
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Additional Information and Resources
Identified resources developed now include:
– Sampling methodology
– Measure calculation
– Validation methodology
– Data abstraction tools
– Data element dictionary
– Initial eligible population criteria- ICD codes, or
diagnosis or clinical description
7
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Library Measure Selection and Data
Abstraction
8
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Clinical Practice Guidelines
Drive the Library of Measures
QPS.2.1 Clinical practice guidelines, clinical
pathways, and/or clinical protocols are used to guide
clinical care.
This standard addresses the creation and adoption of
guidelines, pathways or protocols, and their use in a
leadership driven prioritizing process.
9
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Example: Prevention of Surgical Site Infections
Guidelines Antimicrobial Prophylaxis
Recommendations of Antimicrobial Prophylaxis
‒ Administer prophylactic antimicrobial agents only
when indicated, and select in accordance with
published recommendations as delineated in
national guidelines
‒ Administer by the intravenous route the initial dose
of prophylactic antimicrobial agent
o Prophylactic antibiotic should be received within one hour
prior to surgical incision
10
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Library of Measures: Measure Information
I-SCIP-Inf-1d
Measure Name ‒Prophylactic antibiotics received within one hour prior to
surgical incision for Hip Arthroplasty patients
Rationale
–A goal of prophylaxis with antibiotics is to establish
bactericidal tissue and serum levels at the time of skin incision
Numerator
–Number of surgical patients (hip arthroplasty) with
prophylactic antibiotics initiated within one hour prior to
surgical incision
Denominator
– All selected surgical patients (hip arthroplasty) with no
evidence of prior infection and who are > = 18 years.
11
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
ICD Principal
Procedure for Hip
Arthroplasty
ICD
Principal Diagnosis
of Infection
Other
Surgeries
Surgical
Incision Date
YES
NO
Valid Date
Case NOT in the
I-SCIP-Inf-1d
Initial Population
Case not in Measure
Population-Excluded (B)
NO
YES
YES
Unable to
determine
Run inpatient cases with a Principal Procedure
Code or Principal Procedure of Hip Arthroplasty
on Appendix A, Table 5.04
ICD Principal Diagnosis Code or Principal
Diagnosis on Appendix A, Table 5.09, Infections
Documentation that “Other procedures”
requiring general or spinal/epidural anesthesia
that occurred within three days prior to or after
the principal procedure during this hospital stay.
Documented Principal Procedure Surgical Date:
dd/mm/yyyy
I-SCIP-Inf-1d Prophylactic Antibiotic Received Within One Hour Prior to
Surgical Incision - Hip Arthroplasty
Case Not in Measure
Population-Excluded (B)
Infection Prior
to Anesthesia
Case not in Measure
Population-Excluded (B) YESCheck if there is documentation that the patient
had an infection prior to the Principal Procedure
Patient Age (in years ) =
Admission Date – Birthdate
Run case for patients = >18 years old
Case NOT in the
I-SCIP-Inf-1d
Initial Population
= >18 years
Patient Age <18 years
NO
NO
Case Failed Measure
and is in the
Measure Population (D)
START
I-SCIP-
Inf-1d
K
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Surgical
Incision Time
Valid time
Unable to
determine
Documented Principal Procedure Surgical
Incision Time
Hours and minutes
Case Failed Measure
and is in the
Measure Population (D)
Antibiotic
Timing 1
Received Within 1 hour
Prior to Surgical
Incision Time
Check if the documented antibiotic was
received within one hour (or 2 hours if
Vancomycin, Appendix C, Table 3.8) prior to
Surgical Incision Time: Answer Yes
YES
= > 0 minutes and
=< 60 minutes
for at least
one antibiotic
Case Failed Measure
and is in the
Measure Population (D)
NO
<0 or >60 minutes for ALL antibiotic doses
Case Met Measure
and is in the
Numerator Population (E)
Antibiotic
Administration
Date
Antibiotic
Administration
Time
Documentation of the date the patient
received intravenous antibiotics (IVAB)
closest to and before the principal procedure
incision time
dd/mm/yyyy
Documentation of the time the patient
received intravenous antibiotics (IVAB)
closest to and before the prinicipal procedure
incision time
Hour and minutes
Case Failed Measure
and is in the
Measure Population (D)
Case Failed Measure
and is in the
Measure Population (D)
Unable to
determine
Unable to
determine
Valid date
Valid Time
Antibiotic Name
YES
Case Failed Measure
and is in the
Measure Population (D)
NO
Documentation that the intravenous antibiotic
that the patient received perioperatively was
on the Appendix C, Antibiotic Medications
Table 2.1
Antibiotic Timing 1 = Surgical Incision Date and
Surgical Incision Time –(minus) Antibiotic
Administration Date and Antibiotic Administration Time
I-SCIP-
Inf-1d
K
STOP
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Most Frequently Asked Measurement
Questions What if the Library Measures are not applicable to
the hospital’s clinical service groups/specialties?
– the majority of JCI accredited hospitals
provide clinical services to the measures’
specific population groups of patients
• If you are a specialty hospital and/or need additional
help with measure selection you may contact
bholland@jcrinc.com for assistance.
• If an exception to QPS.3.1, ME.2 is granted, the
survey team will be notified.
– The organization granted an authorized exception
from a Library measure, is NOT exempt from
selecting and gathering data for the relevant QPS.3.1
clinical measures.
14
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Most Frequently Asked Measurement
Questions(continued)
How should a hospital approach selection of measures
from the Library?
– The hospital’s leaders should identify targeted
areas for measurement and improvement based on:
• The hospital’s clinical service areas or patient populations
served,
• high volume patient populations ( diagnoses or
procedures),
• high utilization of resources,
• high risk patients(neonatal, diabetic, etc) and/or
• problematic or newly implemented patient care process.
15
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Most Frequently Asked Measurement
Questions (continued)
How does a hospital identify the measures’ initial
eligible patient population if the hospital does not
have a coding system?
– A hospital abstractor should strive to identify
the measure’s quarterly discharge medical
records using a documented diagnosis or
procedure description.
• Descriptions are located on the code tables next to
the code included in each measure’s initial
population criteria.
• If your hospital uses a different description, contact
bholland@jcrinc.com for assistance..
16
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Most Frequently Asked Measurement
Questions (continued)
What if we have problems or make mistakes with
data abstraction or validation? Hospitals should
strive for data completeness with the understanding
there is an expected learning curve for all hospitals;
some hospitals may need more time and assistance
than others.
17
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Measure Overview Table and QPS Clinical
Areas (continued)
When hospitals determine which (5) measures to
select from the Library of Measures they may consider:
– relevant measures related to one or more of the
(11) “Clinical Areas” identified in the QPS intent
statement.
• Selecting a Library measure related to one or more of the
“Clinical Areas” may
– reduce an unnecessary additional data abstraction burden
for abstractors, since hospitals would be able to count the
related measure as both a Library measure and a “Clinical
Area” measure to meet the QPS.3.1 ME1 and ME2
requirements.
18
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Data Validation
What dose it mean?
Data validation is most important when:
A new measure is implemented
Data will be made public
A change has been made to
the existing measure
The data source has been changed
Introduction of new technology
or new process of care related to the issue of measures
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Just an example
Benchmark
" ومن أحياها فكأنما أحيا الناس جميعا"
Target
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Coming Soon:
Library Specifications, Version 2.0
Validation Table required to use as of January 2013
discharges and may use during the transition stage in
year 2012
21
Quarterly Number
of Medical Records
Originally
Abstracted
Validation Sampling
Requirement
180 records or
greater
At least 5%
<180 records At least 9 sampled
records
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Example of Random Sampling Using the
Version 2.0 Sample Table
Number of a measure’s abstracted “quarterly”
discharge medical records = 120 cases
Sampling Requirement at least 9 medical records
120/9 = 13
Sampling interval number = 13
Select starting point
Then, select every 13th medical record to be included
in the validation sample until you reach the 9 required
records
22
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Credible Data Validation Process Criteria
QPS.5
Re-collection of the original data by a second abstractor
Use a statistical valid sample number of records as defined
in the following table
Compare the original abstracted data with the re-collected
data
Calculating the accuracy by dividing the number of data
elements found to be the same by the total number of data
elements and multiplying by 100.
A 90% accuracy level is a good benchmark
Data elements found not to be the same (do not match with
the original results- take corrective action).
After corrective action implemented, take a new sample and
re- abstract data for accuracy
23
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Possible sources of the inaccuracy of
data
A change in the data collection tool
A change in the formula
A change in the definitions
A change in the source of data collection
Changing the individuals who are involved in the data
collection !
A change in the benchmarking definitions
" ومن أحياها فكأنما أحيا الناس جميعا"
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
What to do in case of the accuracy level
is less than 90%
When data elements are found not to be the same.
Noting the reasons (for example, unclear data definitions)
and taking corrective actions.
Collecting a new sample after all corrective actions
have been implemented to ensure the actions resulted in
the desire accuracy level.
" ومن أحياها فكأنما أحيا الناس جميعا"
© J
oin
t C
om
mis
sio
n Inte
rnatio
nal
Questions & Answers
26