OAKBROOK, Ill. -- Expanded Joint Commission
performance measurement expectations will require accredited hospitals to
begin gathering and using data on an additional set of core performance
measures beginning in January 2004.
The new requirement, approved last month by the Board of Commissioners of
the Joint Commission on Accreditation of Healthcare Organizations (JCAHO),
will increase the scope of hospital collection and reporting of
performance measure data from two to three sets of core measures.
Hospitals can at present choose from four core measure sets that address
acute myocardial infarction, heart failure, community acquired pneumonia,
and pregnancy and related conditions.
"By focusing measurement efforts on the most common inpatient conditions,
hospital data-driven improvement efforts will have the broadest possible
impacts," says Dennis S. O'Leary, MD, president of JCAHO. "These are also
clinical conditions that are of great interest to a variety of regulatory,
purchaser, and consumer groups."
Core measures are part of the Joint Commission's ORYX initiative whose
principal objective is to integrate outcomes and other performance
measurement data into the accreditation process. The goal is to create a
continuous, data-driven accreditation process that focuses on the actual
results of care.
In addition to the current core measures, the Joint Commission is actively
developing new measure sets that address surgical infection prevention,
ICU care, pain management and inpatient pediatric asthma. These measure
sets are expected to become available incrementally over the next six to
An initial group of 10 core measures -- derived from three of the Joint
Commission's current ORYX core measure sets -- has been identified for
voluntary public reporting by The Quality Initiative: A Public Resource on
Hospital Performance. The Quality Initiative is being led by the American
Hospital Association, the Federation of American Hospitals, and the
Association of American Medical Colleges, and supported by the Joint
Commission and the Centers for Medicare and Medicaid Services, among
others. This initiative marks an important milestone in efforts to provide
the public with useful, understandable quality information regarding
patient care and outcomes in individual hospitals.
Increasing the core measurement requirement from two to three measure sets
will now allow accredited hospitals to use ORYX core measure selections
both to satisfy Joint Commission requirements and to fully participate in
The Quality Initiative in a coordinated manner.
The new requirements continue to provide alternatives for the relatively
small number of hospitals to whom the current core measure sets do not
apply. Most of these are specialty (e.g., pediatric, psychiatric)
hospitals. Data gathering and reporting requirements for these hospitals
will also increase modestly beginning in 2004, as follows:
- Hospitals currently reporting data on one core measure set and three
non-core measures will report data on one core measure set and six
- Hospitals currently reporting data on six non-core measures will report
data on nine non-core measures.
- Hospitals currently reporting data on two core-measure sets, but unable
to identify a third core measure set, will report data on two core measure
sets and three non-core measures.
For more information about the Joint Commission's ORYX and core measure
requirements, go to the Joint Commission's website at