Specifications Manual for Joint Commission National Quality Measures (v2018A1)
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Introduction TJC
Version 2018A1

Introduction and Background

The Joint Commission Quality Initiative

In 1987, The Joint Commission announced its Agenda for Change, which outlined a series of major steps designed to modernize the accreditation process. A key component of the Agenda for Change was the eventual introduction of standardized core performance measures into the accreditation process. As the vision to integrate performance measurement into accreditation became more focused, the name ORYX® was chosen for the entire initiative. ORYX® is The Joint Commission's performance measurement and improvement initiative, which integrates outcomes and other performance measure data into the accreditation process.

The ORYX® initiative became operational in March of 1999, when performance measurement systems began transmitting data to The Joint Commission on behalf of accredited hospitals. ORYX® measurement requirements are intended to support Joint Commission accredited organizations in their quality improvement efforts.

The initial phase of the ORYX® initiative provided healthcare organizations a great degree of flexibility in terms of the measures that could be reported. Over time, the ORYX® measures have evolved into standardized sets of valid, reliable, and evidence-based quality measures

Accreditation Process

In January 2000, Joint Commission surveyors began using organization-specific ORYX® Pre-Survey Reports, effectively commencing the use of performance measure data in the survey process.

In 2004, the survey process was substantially modified to be more data-driven and patient-centered thus enhancing its value, relevance, and credibility. Many of the key components of the survey process utilize data derived from the national hospital inpatient quality measures. The survey process now has a greater focus on evaluating actual care processes because patients are traced through the care, treatment and/or services they receive. In addition, surveyors conduct “systems tracers” to analyze key operational systems that directly impact the quality and safety of patient care.

In June 2010 The Joint Commission categorized its process core performance measures into accountability and non-accountability measures.  This approach places more emphasis on an organization's performance on accountability measures — quality measures that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement:

  • Research:  Strong scientific evidence demonstrates that performing the evidence-based care process improves health outcomes (either directly or by reducing risk of adverse outcomes).
  • Proximity:  Performing the care process is closely connected to the patient outcome; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs.
  • Accuracy: The measure accurately assesses whether or not the care process has actually been provided.  That is, the measure should be capable of indicating whether the process has been delivered with sufficient effectiveness to make improved outcomes likely.
  • Adverse Effects:  Implementing the measure has little or no chance of inducing unintended adverse consequences.

Beginning in January 2012, The Joint Commission also incorporated a standards-based expectation for minimum performance on ORYX® accountability measures against which hospitals are surveyed and requirements for improvement (RFIs) can be made

Data Analysis

The Joint Commission has developed a target measure range approach (target analysis) as a basis to evaluate Joint Commission accredited organizations' rating for the performance measures.

The use of target analysis in addition to a control chart is a key feature of the Joint Commission's analytic methods in the ORYX® initiative. The two analyses are alike in that an organization's actual (or observed) performance level is evaluated against a comparative norm, but are fundamentally different as to how such a norm is established. In control chart analysis, the norm is determined from an organization's own historic data so that one may assess the organization's internal process stability. In target analysis, the norm is obtained based on multiple organizations' performance data to evaluate an organization's relative performance level. Therefore, the two analyses evaluate an organization's performance in two distinct perspectives and, as a result, can provide a more comprehensive framework to assess an organization's overall performance level.

ORYX® Performance Measure Report

The ORYX® Performance Measure Report assists health care organizations in using their ORYX® data for ongoing performance improvement activities. Joint Commission surveyors receive an identical copy of the report prior to an onsite survey. Surveyors use the report as a guide to understanding how the organization uses and responds to performance measure data. The report, available quarterly, summarizes performance measure information at both the measure set and individual measure level. This includes highlighting measures with standards compliance issues and performance issues.

Certification Process

The Joint Commission uses two methodologies for performance measurement for disease-specific care programs. Each certified program collects either standardized or nonstandardized measures, as directed by The Joint Commission. During the certification review the program will demonstrate that it has established a data history that supports quality improvement. Selected standardized measure sets have been incorporated in this specification manual to centralize the measures used for Joint Commission programs into one manual. For more information on the certification process refer to The Joint Commission website and the specific certification program of interest.

Quality Check™


In July 2004, The Joint Commission launched a new generation of reporting healthcare information about the quality and safety of care provided in its accredited healthcare organizations across the country.

The Joint Commission's Quality Check™ provides clear, objective data to individuals for the purpose of comparing the performance of local hospitals, home care agencies, nursing homes, laboratories, and ambulatory care organizations with others on state and national levels. Additionally, The Joint Commission provides hospital-specific information about clinical performance in the care of patients for the ORYX® measures. In addition, Quality Check™ includes HCAHPs data and the CMS 30-day mortality measures.

Individuals are also able to determine how healthcare organizations compare with others in meeting national requirements that help them prevent devastating medical accidents. The requirements specifically seek to avoid misidentification of patients, surgery on the wrong body part, miscommunication among caregivers, unsafe use of infusion pumps, medication mix-ups, problems with equipment alarm systems, and infections acquired in the healthcare setting.

Consumers can access Quality Check™ at http://www.qualitycheck.org and search for healthcare organizations by name, type, and/or location. Interactive links to information are designed to help individuals better understand how to use and interpret the information presented.

Annual Report

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety has been released annually since 2008. This comprehensive report summarizes the performance of all Joint Commission-accredited hospitals on ORYX® accountability measures.

National Quality Forum

The NQF has approved a set of national voluntary consensus standards for measuring the quality of hospital care. These measures will permit consumers, providers, purchasers, and quality improvement professionals to evaluate and compare the quality of care in general acute care hospitals across the nation using a standard set of measures. The majority of the Joint Commission's measures are endorsed by NQF and are denoted on the measure information forms.

National Quality Measures Clearinghouse

The National Quality Measures Clearinghouse (NQMC™), sponsored by AHRQ, U.S. Department of HHS, has included Joint Commission measures in its public database for evidence-based quality measures and measure sets. NQMC is sponsored by AHRQ to promote widespread access to quality measures by the healthcare community and other interested individuals.

Introduction TJC
Specifications Manual for Joint Commission National Quality Measures (v2018A1)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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