You will find many answers to questions about using American Joint Replacement Registry (AJRR) participation for The Joint Commission Advanced Total Hip and Knee Replacement (THKR) Certification below. 

 

1. How do sites participate?
2. How do I get started with the AJRR if my site is not already enrolled?
3. What data do I need for my site survey?
4. What THKR measures does AJRR support? 
5. How can sites view their data?
6. How are the performance measures calculated?
7. Are the measures separated by inpatient and outpatient status?
8. Do you follow The Joint Commission Measure Specification?
9. How do I know which cases are meeting a performance measure?
10. Do I need to submit all The Joint Commission fields in the data specifications?
11. Is there a way to export the data behind the tables in the dashboards?
12. Why does my denominator vary across the THKR measures?
13. Why is my THKR-1 (Regional Anesthesia) measure denominator higher than the other metrics?
14. How long will it take for data to populate in the dashboards?
15. What do I do if my THKR measure tiles are blank or are not displaying the performance rate expected based on cases submitted?

 

1. How do sites participate?

The Joint Commission Advanced THKR Certification requires participation in the AJRR for performance measures and quality improvement purposes. Sites must be contracted with AJRR and submitting data to the Registry on at least a quarterly basis.

Additional resources can be found here.

 

2. How do I get started with the AJRR if my site is not already enrolled?

To find out if your site is already participating or to start the process of joining AJRR, reach out to the AAOS Registry Engagement team at RegistryEngagement@aaos.org or (847) 292-0530.

 

3. What data do I need for my site survey?

• For initial certification, at least four months of data for each performance measure must be available at the time of the on-site review.
• For re-certification, 12-24 months of program data must be available at the time of the on-site review. At least the last 12 months of program data should be available at the time of the Intra-cycle monitoring phone call with the reviewer.

For more information and resources on the site survey process, visit The Joint Commission Advanced THKR Certification website.

 

4. What THKR measures does AJRR support? 

There are five performance measures supported by the AJRR for total hip and knee replacements:

1. Regional Anesthesia
2. Postoperative Ambulation on the Day of Surgery
3. Discharged to Home
4. Preoperative Functional/Health Status Assessment
5. Postoperative Functional/Health Status Assessment

 

5. How can sites view their data?

AJRR has dashboards on the RegistryInsights® platform that display a site’s performance measure data for The Joint Commission Advanced THKR Certification measures. To view calculated measures in the RegistryInsights dashboard, sites need to submit The Joint Commission elements reviewed in sections 1.1 and 1.2 of the Registry Participation Toolkit and found in our data specifications.

 

6. How are the performance measures calculated?

The dashboard analytics filter out The Joint Commission exclusion and exemption criteria for each case based on submitted data, displaying only those applicable to the measure. Built-in functionalities allow for quick highlighting of graph bars to show a detailed legend including the numerator and denominator counts for each hip and knee metric. Additional details on the measure calculations can be reviewed in The Joint Commission Registry Participation Quick Reference Guide or in Sections 1.1 and 1.2 of the Registry Participation Toolkit.

 

7. Are the measures separated by inpatient and outpatient status?

Dashboard visuals are separated out by joint for each measure, displaying aggregate numerator and denominator data across all case types. Additional case details, including the care setting, can be found in The Joint Commission Data Detail Report link under the THKR charts. See section 3.3 of the THKR Registry Participation Toolkit for additional information on accessing and using this report. A future update will include an Inpatient/Outpatient filter across all performance measures.

 

8. Do you follow The Joint Commission Measure Specification?

Yes, our inclusion and exclusion criteria built into the measure calculations follows The Joint Commission specification for all five measures. The only exception is the PROMs data, where AJRR has an additional requirement for the full PROMs survey so sites may track improvement and benchmarking in the RegistryInsights dashboard.

 

9. How do I know which cases are meeting a performance measure?

There is a Joint Commission Data Detail Report available on the performance measures tab under the THKR measure charts. This report provides detail on whether individual cases met the metric and detail on the exclusion criteria data that would remove a case from the denominator. This report can also be filtered by care setting (inpatient/outpatient), procedure data, joint, and measure. For more information, see section 3.3 of the Registry Participation Toolkit.

 

10. Do I need to submit all The Joint Commission fields in the data specifications?

Yes, to accurately calculate the measures, all fields need to be submitted. Some of the exclusion criteria will not apply to all cases (ex: the TJC_Rgnl_Asth_Exemption will only require a response if regional anesthesia was not performed or attempted). In the case where a response is not applicable, the field can be populated as Not Reported or NR.

 

11. Is there a way to export the data behind the tables in the dashboards?

We are unable to allow sites to export files with PHI that are not protected by passwords. However, the TJC Data Detail Report replaces that functionality and can be encrypted. The TJC Data Detail Report can be found in the Performance tab on RegistryInsights.

 

12. Why does my denominator vary across the THKR measures?

Some exclusion criteria apply across all 5 measures, such as revision procedures, however, each measure also has its own exclusions that could create varying denominator values. For example, a patient may have a medical reason documented for not ambulating the day of surgery but still had regional anesthesia and was discharged to home. This would remove the case from the denominator of THKR-2 but would remain in THKR-1 and 3.

 

13. Why is my THKR-1 (Regional Anesthesia) measure denominator higher than the other metrics?

THKR-1 is the only measure that does not exclude fracture cases from the denominator, often creating a higher eligible case count for this measure. Cases indicating that regional anesthesia was attempted and failed or medically contraindicated are also treated as an exemption, not an exclusion, per The Joint Commission Measure Specification, meaning the case remains in the numerator and is not removed from the denominator. See sections 1.1 and 1.2 of the Registry Participation Toolkit or the Registry Participation Quick Reference Guide for additional detail on the data element responses and measure calculation for THKR-1.

 

14. How long will it take for data to populate in the dashboards?

We recommend sites allow 2-3 days for data to refresh in the dashboards. If you are still not seeing your submitted data populate, please reach out to RegistrySupport@aaos.org or call 1-800-999-2939.

 

15. What do I do if my THKR measure tiles are blank or are not displaying the performance rate expected based on cases submitted?

If your data is missing or lower than expected in the dashboards, you can take the below steps to review your data submission. If after reviewing you are still not seeing expected data in your dashboard, please reach out to RegistrySupport@aaos.org or call 1-800-999-2939

• #1 - File Submission Verification
  • Recent procedure and/or PROMs data files are visible in your RegistryInsights home page file submission history
  • Files are visible and successfully processed
    • Move to #2 - Data Element Review
  • File has multiple rejections
    • Click the blue “view” link to drill down to the case rejection details and identify failed fields
    • Correct these fields and resubmit rejected cases
  • A recent file submitted is not visible in RegistryInsights or you have questions about how to correct your case rejections
    • Reach out to RegistrySupport@aaos.org or call 1-800-999-2939
      
      
• #2 - Data Element Review*
  • THKR-1
    • Values are populated for TJC_AnesthesiaType and TJC_Rgnl_Ansth_Exemption data elements in the procedure file
  • THKR-2
    • Values are populated for TJC_Ambulation data element in the procedure file
  • THKR-3
    • Values are populated for TJC_DSCHDISPCODE, TJC_Discharge_Exclusion, and TJC_Admit_Source in the procedure file
  • THKR-4
    • A pre-op general health assessment (PROMIS-10 or VR-12) AND a joint-specific functional status assessment (HOOS or KOOS) completed within 90 days before surgery are submitted on the PROMs file or via the RegistryInsights PRO Portal
    • PROMsTime data element is populated with pre-operative
    • Procedure for the pre-op PROMs has also been submitted
    • Patient matching data fields outlined in section 1.4 of the Registry Participation Toolkit are complete
  • THKR-5
    • A post-op general health assessment (PROMIS-10 or VR-12) AND a joint-specific functional status assessment (HOOS or KOOS) completed 30-150 days after surgery are submitted on the PROMs file or via the RegistryInsights PRO Portal
    • PROMsTime is populated with 3-month
    • Procedure for the post-op PROMs has also been submitted
    • Patient matching data fields outlined in section 1.4 of the Registry Participant Toolkit are complete

*Use the table in section 1.1 to identify data element values used to calculate numerator cases

• #3 - Additional Dashboard Considerations
  • Performance measure tiles do not populate if the rate is 0%, so there needs to be at least 1 case eligible for the numerator to see data in any of the THKR measure visuals
  • PROMs measures, THKR-4 and 5, will not populate unless both general health and functional assessments have been submitted and are linked to the applicable submitted procedure