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Joint Commission Expands Performance Measurement Requirements for General Medical/Surgical Hospitals

The Joint Commission announces that it will expand performance measurement requirements for accredited general medical/surgical hospitals from four to six core measure sets. The additional requirements, which are part of The Joint Commission’s ORYX® performance measurement initiative to stimulate and guide quality improvement efforts, will take effect Jan. 1, 2014.

Four of the six measure sets will be mandatory for all general medical/surgical hospitals that serve specific patient populations addressed by the measure sets and related measures. The measure sets address acute myocardial infarction (AMI), heart failure, pneumonia and the Surgical Care Improvement Project (SCIP). These core measure sets are common to several federally legislated programs and selected most frequently by hospitals.

For hospitals with 1,100 or more births per year, the perinatal care measure set will become the mandatory fifth measure set. The Joint Commission chose the perinatal care measure set because of the high volume of births in the United States (4 million per year) and because it affects a significant portion of accredited hospitals. The Joint Commission will monitor the threshold of 1,100 births over the first four to eight quarters of data collection to reassess ongoing applicability. The Joint Commission expects that this threshold will be modified over time so that more hospitals are included and strongly encourages hospitals to consider adopting this measure set before the required effective date of Jan. 1, 2014.

The sixth measure set (or fifth and sixth measure sets, for hospitals with fewer than 1,100 births per year) will be chosen by all general medical/surgical hospitals from the approved complement of core measure sets. These sets are related to children’s asthma care, emergency department care, hospital-based inpatient psychiatric services, hospital outpatients, immunization, tobacco treatment, stroke, substance use and venous thromboembolism. The Joint Commission expects that requirements will increase over time, depending on the national healthcare environment, emerging national measurement priorities and hospitals’ ever-increasing capability to electronically capture and transmit data.

Although hospitals must modify and update measure set selections two months before the start of data collection on Jan. 1, 2014, data received for the newly added measure sets and measures will not be incorporated into calculations for either Performance Improvement (PI) Standard PI.02.01.03 (which requires that the hospital improve its performance on ORYX accountability measures) or the Top Performers on Key Quality Measures™ program until sufficient data are received. This will provide hospitals a minimum of 12 months and up to 23 months of experience with the new measure sets before the data are included in performance calculations.

Performance measurement requirements for critical access hospitals and specialty hospitals, such as children’s hospitals and psychiatric hospitals, will continue as currently defined until other applicable metrics are identified and implemented.

For more information about performance measurement and accreditation, visit:

Source:  Joint Commission

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