The Joint Commission

Section 2: Aggregate Data Dictionary (ALC)

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Last updated: Aug 28, 2024 by Patty Craig
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Joint Commission Guide for Data Entry of Chart-Abstracted Measures for Assisted Living Community (ALC)
Applicable calendar years:
- 01-01-2023 (1Q2023) through 12-31-2023 (4Q2023)
- 01-01-2024 (1Q2024) through 12-31-2024 (4Q2024); as of March 2024

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Introduction

This section of the manual describes the aggregate data elements assisted living organizations must calculate prior to entering their chart-abstracted measure data into the Direct Data Submission Platform (DDSP). It includes the definition and allowable values for each aggregate data element. In addition, data edits and statistical equations are provided as appropriate.

Data Edits and Statistical Equations

For each aggregate data element, data edits and statistical equations are provided below as appropriate. The statistical equations have been provided to assist in your proper calculation of these data element. The edits will be executed on the DDSP and will result in an error message. In addition, the DDSP will ensure data is entered correctly from the perspective of allowable values and whole numbers.

Stratified Measures

Stratified measures are classified into several groups (strata) to assist in the analysis and interpretation of the measure. The overall or un-stratified measure evaluates all the strata together. The stratified measure or each stratum consists of a subset of the overall measure.

Measures which are stratified require the appropriate aggregate data to be entered for each stratum associated to the measure. Currently, only ALC-05 is stratified.

Attestation Of Zero Cases

Assisted living organizations will be capable of attesting to having zero denominator cases.

Denominator:  If a zero is entered into the Denominator field for a month, the user will be promoted to check the Zero Denominator Attestation box to attest that the zero Denominator count is valid.

Aggregate Data Elements Overview

Currently, all the ALC measures are proportion measures. The aggregate data elements in this Guide define what is to be inputted into each field.

The DDSP calculates the following data elements based upon the aggregate data entered for each measure, or strata and reporting time period.

Numerator (ALC-05):

The DDSP automatically calculates the numerator for ALC-05a and ALC-05b in the submission form. The counts for Number of Staff Employed and Number of Direct Care Staff Employed, which are the numerator data elements, will be entered into the DDSP along with the denominator counts so that the numerator can automatically be calculated by the DDSP.

Refer to the data element Numerator below for how this data element is being calculated for ALC-05.

Observed Rate (all measures):

Observed rates are used to measure assisted living organization performance. It is based on the aggregated data entered by the ALC organization.

The Observed Rate is calculated as the number of Numerator cases divided by the number of Denominator cases (Numerator / Denominator). The Observed Rate is calculated to 4 decimals and rounded to 3 decimals where 5 rounds up.

For ALC-05, an Observed Rate is multiplied by 100 (Numerator / Denominator) *100 and a separate Rate is calculated for both stratum (ALC-05a and ALC-05b).

Data Element Dictionary Terms

Name:

A short phrase identifying the aggregate data element.

Aggregated For:

Identifies the type of measure this data element is aggregated for.

Definition:

A detailed explanation of the data element, including statistical equations when appropriate.

Allowable Values:

A list of acceptable responses for this data element.

Edits:

Data integrity edits and other actions that the DDSP will apply to the aggregate data.

Alphabetical List of All Data Elements

Data Element Name

Aggregated For

Denominator

Proportion measures

Number of Direct Care Staff Employed

Proportion measures – ALC-05b

Number of Staff Employed

Proportion measures – ALC-05a

Numerator

Proportion measures

Proportion Measures

Proportion measures are measures in which the value of each measurement is expressed as a proportion where the numerator is expressed as a subset of the denominator.

The following aggregate data elements are required to be entered for proportion measures:

  • Denominator

  • Number of Direct Care Staff Employed

  • Number of Staff Employed

  • Numerator

Name:

Denominator

Aggregated For:

Proportion measures

Definition:

Summation of denominator cases (proportion) for the measure's population during the month.

Do not eliminate or suppress outliers.

ALC-01, 02, 03, 04, 05a, and 05b:

The Denominator must be entered for the month. The values of the following measure data elements are entered into the Denominator field within the DDSP for the associated measure.

ALC-01:    Assisted Living Community Resident

ALC-02:    Assisted Living Community Resident

ALC-03:    New Resident

ALC-04:    New Resident

ALC-05a:  Number of Positions

ALC-05b:  Number of Direct Care Staff Positions

Note:  The definitions of the above measure data elements is provided within the Specification Manual for Joint Commission Assisted Living Community Quality Measures.

Allowable Values:

0 through 199 (whole numbers only)

Note:  Assisted living organizations entering a zero for this data element will be required to attest that they have no cases in the denominator (i.e., ‘zero denominator’) for the measure for the month. Organizations with denominator cases are expected to enter the appropriate value for each measure or strata.

Edits:

ALC-05a:

  • Denominator [Number of Positions] must be <= Number of Staff Employed

ALC-05b:

  • Denominator [Number of Direct Care Staff Positions] must be <= Number of Direct Care Staff Employed

 

Name:

Number of Direct Care Staff Employed

Aggregated For:

Proportion measures – ALC-05b

Definition:

The definition of Number of Direct Care Staff Employed is provided within the Specification Manual for Joint Commission Assisted Living Community Quality Measures.

Do not eliminate or suppress outliers.

Note:  This measure data element is used by the DDSP to calculate the ALC-05b Numerator. See Numerator below for more information.

Allowable Values:

0 through 199 (whole numbers only)

Edits:

  • Number of Direct Care Staff Employed must be <= Number of Staff Employed

 

Name:

Number of Staff Employed

Aggregated For:

Proportion measures – ALC-05a

Definition:

The definition of Number of Staff Employed is provided within the Specification Manual for Joint Commission Assisted Living Community Quality Measures.

Do not eliminate or suppress outliers.

Note:  This measure data element is used by the DDSP to calculate the ALC-05a Numerator. See Numerator below for more information.

Allowable Values:

0 through 199 (whole numbers only)

Edits:

None

Name:

Numerator

Aggregated For:

Proportion measures

Definition:

Summation of numerator cases in a measure's population during the month.

Do not eliminate or suppress outliers.

ALC-01, 02, 03, and 04: 

The Numerator must be entered for the month. The values of the following measure data elements are entered into the Numerator field within the DDSP for the associated measure.

ALC-01:    Off-Label Antipsychotic Drug Prescribed

ALC-02:    Fall with Transfer to Hospital

ALC-03:    Resident Preferences and Goals of Care

ALC-04:    Advanced Care Plan / Surrogate Decision Maker

ALC-05:

The Numerator is calculated by the DDSP as follows:

ALC-05a calculation: (Number of Staff Employed – Denominator)

ALC-05b calculation: (Number of Direct Care Staff Employed – Denominator)

Note:

Allowable Values:

0 through 199 (whole numbers only)

Edits:

ALC-01, 02, 03, and 04: 

  • Numerator must be <= Denominator

ALC-05a:

  • (Number of Staff Employed – Denominator [Number of Positions]) must be >= zero (0)

ALC-05b:

  • (Number of Direct Care Staff Employed – Denominator [Number of Direct Care Staff Positions]) must be >= zero (0)

 

Continue to the next section: Section 3: Measure Exclusions

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