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Library of Measures and Data Validation as Required by Joint Commission International

Zakaria Zaki Al Attal PhD, CPHQ JCI consultant

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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
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International Library of MeasuresMeasure Sets

1) Acute Myocardial Infarction (AMI) 6 2) Heart Failure (HF) 3 3) Stroke (STK) 4 4) Childrens 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

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JCI Accredited Hospitals (313) Respond to Library of Measures Survey

Survey Completed Survey Not Completed

122, 39%

191, 61%

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International Hospitals Selections of Library Measures (36 measures) Top 6 Measures Selected to Date
46, 6%
37, 5% 37, 5%

70, 9% I-AMI-1 ASA on arrival I-AMI-2 ASA on discharge 439, 59% 44, 6%

NSC-2 Pressure ulcers

I-NSC-4 All falls I-NSC-5 Falls with injuries I-SCIP-1 Antibiotics within 1 hr.

75, 10%


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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

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set, or a total of 5 measures from different measure sets.

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
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Library Measure Selection and Data Abstraction

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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

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leadership driven prioritizing process.

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
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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

A goal of prophylaxis with antibiotics is to establish bactericidal tissue and serum levels at the time of skin incision

Number of surgical patients (hip arthroplasty) with prophylactic antibiotics initiated within one hour prior to surgical incision
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Denominator All selected surgical patients (hip arthroplasty) with no

evidence of prior infection and who are > = 18 years.


Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hip Arthroplasty

Run inpatient cases with a Principal Procedure Code or Principal Procedure of Hip Arthroplasty on Appendix A, Table 5.04

ICD Principal Procedure for Hip Arthroplasty


Case NOT in the I-SCIP-Inf-1d Initial Population


Patient Age (in years ) = Admission Date Birthdate Run case for patients = >18 years old

Patient Age

<18 years

Case NOT in the I-SCIP-Inf-1d Initial Population

= >18 years

ICD Principal Diagnosis Code or Principal Diagnosis on Appendix A, Table 5.09, Infections

ICD Principal Diagnosis of Infection


Case not in Measure Population-Excluded (B)


Check if there is documentation that the patient had an infection prior to the Principal Procedure

Infection Prior to Anesthesia


Case not in Measure Population-Excluded (B)


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.

Other Surgeries


Case Not in Measure Population-Excluded (B)


Documented Principal Procedure Surgical Date: dd/mm/yyyy

Surgical Incision Date

Unable to determine

Case Failed Measure and is in the Measure Population (D)

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Documented Principal Procedure Surgical Incision Time Hours and minutes

Surgical Incision Time

Unable to determine

Case Failed Measure and is in the Measure Population (D)

Valid Time

Documentation that the intravenous antibiotic that the patient received perioperatively was on the Appendix C, Antibiotic Medications Table 2.1

Antibiotic Name


Case Failed Measure and is in the Measure Population (D)


Documentation of the date the patient received intravenous antibiotics (IVAB) closest to and before the principal procedure incision time dd/mm/yyyy

Antibiotic Administration Date

Unable to determine

Case Failed Measure and is in the Measure Population (D)

Valid date

Documentation of the time the patient received intravenous antibiotics (IVAB) closest to and before the prinicipal procedure incision time Hour and minutes

Antibiotic Administration Time

Unable to determine

Case Failed Measure and is in the Measure Population (D)

Valid time

Antibiotic Timing 1 = Surgical Incision Date and Surgical Incision Time (minus) Antibiotic Administration Date and Antibiotic Administration Time

NO <0 or >60 minutes for ALL antibiotic doses

Case Failed Measure and is in the Measure Population (D)

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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

Antibiotic Timing 1 Received Within 1 hour Prior to Surgical Incision Time

YES = > 0 minutes and =< 60 minutes for at least one antibiotic

Case Met Measure and is in the Numerator Population (E)

Most Frequently Asked Measurement Questions

What if the Library Measures are not applicable to the hospitals 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 for assistance. If an exception to QPS.3.1, ME.2 is granted, the survey team will be notified.
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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.

Most Frequently Asked Measurement Questions(continued)

How should a hospital approach selection of measures from the Library? The hospitals leaders should identify targeted areas for measurement and improvement based on:
The hospitals 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.


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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 measures 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 measures initial population criteria. If your hospital uses a different description, contact for assistance..


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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.
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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.


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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
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Just an example


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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 Quarterly Number Validation Sampling Requirement of Medical Records Originally Abstracted 180 records or greater <180 records At least 5% At least 9 sampled records
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Example of Random Sampling Using the Version 2.0 Sample Table

Number of a measures 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


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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

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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 !
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A change in the benchmarking definitions


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

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the desire accuracy level.


Questions & Answers

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