CANDIDATE PERFORMANCE MEASURE INFORMATION

Transcription

1 Instructions: Complete for each performance measure submitted to The Joint Commission for potential use as in the Sudden Cardiac Arrest standardized performance measure set. PLEASE TYPE OR PRINT GENERAL CONTENT: A. Indicate if this measure is in the public domain or proprietary. a. Public domain: belonging to the health care community at large; unprotected by copyright and subject to appropriation by anyone. b. Proprietary: owned, copyrighted, or for which exclusive legal rights are held. B. How would improvement be noted for this measure? a. An increase in the rate, score, or number of occurrences (e.g., immunizations) b. A decrease in the rate, score, or number of occurrences (e.g., surgical site infections) c. Either an increase or a decrease in the rate / score / number of occurrences, depending upon the context of the measure (e.g., utilization) C. Check type of measure: Process Outcome Structure D. Length of time in use: E. What is the purpose of measure? Quality Improvement Accountability Surveillance G. To which age grouping(s) does the performance measure population apply? (Check all that apply, unless applicable to all ages, then only check all age groups. ) a b c d All age groups 1 day-17 years 18 years and over Other (specify) H. Performance Measure Name: Use 50 words or less; provide enough information to uniquely identify this measure. This can be the same or a shortened version of the numerator statement, such as "Cardiac arrest within two post-procedure days of procedure involving anesthesia administration. _ IMPORTANCE: Extent to which a measure reflects a variation in quality, low levels of overall performance, and the extent to which it captures key aspects of the flow of care Briefly describe the rationale for this measure of performance (for example, specific literature references, evidence based information, expert consensus, usefulness in accreditation for comparisons across health care organizations, and so forth). Why is this an important measure? Attach supporting documentation and references 1

2 SCIENTIFICALLY ACCEPTABLE: Measure is scientifically sound if it produces consistent and credible results when implemented NOTE: Complete "Numerator and Denominator Statements" if this measure is reported as a proportion or ratio. If a performance measure does not have both a numerator and a denominator, skip items #1 and #2 and use item #3, Continuous Variable Statement to describe measure. 1. Numerator Statement: A statement that depicts the portion of the denominator population that satisfies the condition of the performance measure to be an indicator event. List Numerator data elements (elements used specifically to calculate the numerator including inclusion and exclusion criteria). 2. Denominator Statement: A statement that depicts the population of interest and evaluated by the performance measure. In the case of a proportion, the denominator encompasses the numerator. List Denominator data elements (elements used to determine measure population eligibility including inclusion and exclusion criteria). 3. Continuous Variable Statement; A statement that describes a continuous variable performance measure when numerator and/or denominator statements are not appropriate - For example, "Trauma patients with head computerized tomography (CT) scan performed: time from emergency department or trauma unit arrival to initial CT scan." NOTE: Complete if this measure is reported as a central tendency/continuous variable, NOT a proportion or ratio. Use this item only when the performance measure does not have numerator and denominator statements. 2

3 List continuous variable data elements (elements used to construct the measure). 4. Risk Adjustment: Refers to whether this measure has been adjusted to control for, reduce, or remove, the influences of factors that differ among groups being compared. The purpose of risk adjustment is to make possible the generation of fair comparisons on performance measure data across participating health care organizations. a. This measure is risk adjusted on the basis of patient factors. Yes, Continue to b No, and we have no plans to risk adjust on the basis of patient factors due to: b. Provide a description and definition of the risk adjustment model (s) and/or stratification approach (es), including the statistical processes employed to build and test the model (s). (if applicable) 5. Measure Specifications: Refers to the information needed to implement this measure. a. Provide a list of data elements used to calculate and risk adjust, if applicable, this measure. For each data element, include the following information: Data element name; Data element definition, include ICD-9-CM codes if applicable; Data element allowable values; Data element length (e.g., number of digits or characters) and format (e.g., alpha/numeric, date); Data element purpose (e.g., numerator calculation, denominator calculation, risk adjustment); Data element recommended data source; and Data element data integrity edits. b. A calculation algorithm is available for this measure and consistently applied across all participating health care organizations. That is, the ordered sequence of data element retrieval and aggregation through which numerator and denominator events or continuous variable values are identified for this measure is documented, and applied across all health organizations using this measure. 1) Yes, (please submit) 2) No, but we have plans to have in place by /. (month / year) 3) No, we have no plans 6. Indicate what testing, as defined below, this performance measure has undergone. (Check all that apply.) a) 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. b) Population verification - The extent to which the entire population of interest, and only the population of interest, is identified through data collection. 3

4 c) Discriminatory capability - The extent to which a performance measure demonstrates variation across multiple health care organizations. Comparability assessment of a measure d) Relevance - The applicability and / or pertinence of the performance measure to its users and customers. For Joint Commission purposes, face validity is subsumed in this category. e) Reliability - The ability of the performance measure to accurately and consistently identify the events it was designed to identify within and across health care organizations. f) Validity - The ability to identify opportunities for improvement in the quality of care or services provided; demonstration that use of this measure results in improvements in outcomes and/or quality of care/services. g) Measure has not undergone testing. USEABLE: Reflects the extent to which intended audiences (e.g. consumers, purchasers, and accreditation organizations) can understand the results of the measure and are likely to find them useful for decision making. Measure Interpretability: Refers to the usefulness of the measure for differentiating performance among health care organizations. This includes the ability of the measure to accurately identify existing variation across multiple health care organizations. Describe the established benchmark of best practices for this measure, if one exists, and how it was identified. FEASIBLE: Based on the way in which data is obtained within the normal flow of clinical care and the extent to which an implementation plan can be achieved. Data Collection Effort: Provide copies of data collection tools and instructions, if available a. Data for this measure are collected: Concurrently Retrospectively Other, please explain Electronic Manual b. Document the frequency of data currently being reported; and if data can be reported in unique monthly increments (include length of time history). Monthly Semi-annual Other Quarterly Annual c. Provide estimates on the costs (e.g., financial, personnel, time) required to collect, enter, and practice quality control on the data for the measure. d. Describe the amount and type of training and level of expertise required for accurate date collection. 4

5 CONTACT INFORMATION* Date: Name/Title of Contact Person (if further information is required): * Please specify the individual most appropriate to contact should further information be required regarding the contents of the measure submission. It may be appropriate for the contact person to be different from the person authorized to submit the measure. Organization: Address: City: State: Zip: Phone: Fax: Signature of Person Authorized to Submit Measure: 5