Measure Sampling JCI

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 Appendix I: Measure Sampling

Specification Manual for the Joint Commission International Library of Measures Version 2.0, effective for January 2013 discharges (1st Quarter 2013) ©2011 Joint Commission International 1

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Appendix I: Measure Sampling Introduction Sampling is a process of selecting a representative part of the population of interest in order to estimate the organization’s performance, without collecting data for its entire population. Using a statistically valid sample, an organization can measure its performance in an effective and efficient manner. Sampling is a particularly useful technique for performance measures that require primary data collection from a source such as the medical record. Sampling should not be used unless the organization has a large enough number of cases in the measure ’s initial eligible population because a fairly large number of sample cases are needed to accurately reflect the organization’s performance. Organizations with large patient volumes may perform data collection on a sample of the total population, but sampling is not required. To obtain statistically valid sample data, the sample size should be carefully determined and the sample cases should be randomly selected such that individual cases in the population have an equal chance of being selected. Only when the sample data truly represent the whole population can the sample-based performance measure data be meaningful and useful. Guidelines for effective sampling procedures follow. Sampling may be used for all measures in the Library of Measures except for I-HBIPS2, I-HBIPS-3, I-NCS-2, I-NSC-4 and I-NSC-5. These measures cannot be sampled because they are event-based measures.

Sampling Availability If an organization decides to sample a measure ’s or measure set ’s initial eligible population, sampling should be applied to all monthly discharge medical records identified as part of the inpatient initial eligible population. Initial eligible population criteria are described in each measure set chapter of the specification manual. The initial eligible population should be identified by using available databases or other information repositories that contain monthly patient discharge information, International Classification of Diseases (ICD) diagnosis/procedure codes or patient diagnoses or procedures, and other necessary administrative data (e.g., patient age). Sampling should be undertaken on a monthly basis. Specification Manual for the Joint Commission International Library of Measures Version 2.0, effective for January 2013 discharges (1st Quarter 2013) ©2011 Joint Commission International 2

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Appendix I: Measure Sampling Sample Size Requirements Hospitals selecting sample cases for Library Measures should ensure that its measure ’s or measure set’s  initial patient population(s) and sample size(s) meet the following conditions:

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The number of discharged cases to be sampled on a monthly basis is determined in accordance with the following sampling table: Measure Sampling Table Total Monthly Initial Patient Population Size (N ) for the Selected Measure >= 59