You will find many answers to questions about using ASR participation for The Joint Commission Advanced Certification in Spine Surgery (ACSS) below. Additional resources can be found here.

 

1. How do sites participate?

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

 

2. How do I get started with the ASR if we are not already enrolled?

To find out if your site is already participating or to start the process of joining ASR, reach out to the Registry Engagement team at Engagement@AmericanSpineRegistry.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 twelve 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 The Joint Commission Advanced Certification in Spine Surgery website.

 

4. How many ACSS measures does ASR support?

ASR supports four performance measures for each module – cervical and lumbar.

  • Surgical Site Infection Rates
  • New Neurological Deficits
  • Unplanned Return Visits to the OR
  • Pre- and Post-operative PROMs

 

5. What level of participation meets the requirements for ACSS?

ASR has two levels of participation: Standard and Vanguard. The same contracting and pricing structure applies to both designations. Vanguard simply reflects the additional data collection and extended PROMs follow ups. Both allow for reporting on the ACSS performance measures.

 

6. How will my site collect and submit data for these measures?

Data collection for the ACSS program is completed via ICD-10 coding. Coding associated with a patient case would trigger inclusion in the measure calculation. Codes are available on the purple ACSS tabs within the ASR Data Specifications documents for each module. Refer to sections 1.1-1.3 and section 2 of the Registry Participation Toolkit or the Registry Participation Quick Reference Guide for more detail on data elements and ASR submission.

 

7. How can sites view their data?

ASR dashboards in the RegistryInsights® platform display a site’s performance measure data for the The Joint Commission ACSS measures. To view calculated measures in the RegistryInsights dashboard, sites need to submit all 3 file types – Procedure, PostOp, and PROMs. An ACSS Coding list used to identify numerator inclusion is in the ASR Data Specifications. Refer to section 1.2 for additional detail.

 

8. How are the performance measures calculated?

The dashboard analytics utilize the ACSS diagnosis coding to identify measure eligible cases from procedure file submissions to calculate measure denominators. The measure numerators are calculated from ACSS diagnosis coding submitted with readmission cases in the PostOp file and linked to primary procedures through matching the, patient, procedure date, and module (cervical or lumbar). Built-in functionalities allow for quick highlighting of graph bars to show a detailed legend including the numerator and denominator counts for each metric. Additional detail on the measure calculation can be reviewed in sections 1.1 and 3.3 of the Registry Participation Toolkit or in the Registry Participation Quick Reference Guide.

 

9. 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 Support@AmericanSpineRegistry.org or call 1-800-999-2939.

 

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

If your data is missing or performance rates are higher 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 Support@AmericanSpineRegistry.org or call 1-800-999-2939

  • #1 – File Submission Verification
    • Recent Procedure, PostOp and 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
  • #2 – Data Element Review*
    • ACSS-01-03 and ACSS 05-07
      • There was a readmission case(s) submitted for the month in question
      • The RE_DX fields submitted include one of the ACSS diagnosis codes listed in the data specifications
        • If no, this does not meet the inverse metric numerator inclusion criteria and no data will display in the ACSS tiles
      • Patient matching data fields outlined in section 1.4 of the Registry Participation Toolkit are complete
    • ACSS-05 and ACSS-08
      • A pre-op general health assessment AND a spine-specific functional status assessment was completed within 90 days before surgery AND within 30-150 days after surgery
      • Both pre- and post-op surveys are submitted on the PROMs file or via the RegistryInsights PRO Portal
      • PROMsTime data element is populated with pre-operative or 3-month for the respective pre- and post-operative time points
      • Procedure for the associated PROMs has also been submitted
      • Patient matching data fields outlined in section 1.4 of the Registry Participation Toolkit are complete

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

    • #3 – Additional Dashboard Considerations
      • PROMs measures will not populate unless both general health and functional assessments have been submitted for both the pre- and post-op time points and are linked to the applicable submitted procedure