Specifications Manual for Joint Commission National Quality Measures (v2019A1)
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Introduction TJC
Version 2019A1

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 valid, reliable, and evidence-based quality measures

The initial CMS/Joint Commission alignment efforts addressed chart-abstracted measures and subsequently both organizations have worked on aligning as closely as possible the electronic clinical quality measures (eCQMs).

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 placed 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.

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, available quarterly, is designed to support and help guide Joint Commission-accredited hospitals in their performance assessment and improvement activities through the use of summary dashboards and comprehensive measure details depicting the organization’s performance on each measure for which The Joint Commission receives data from the organization. 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.

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™

Quality Check is a directory of the more than 20,000 Joint Commission–accredited and certified health care organizations and programs throughout the United States. The Joint Commission Quality Report differentiates health care organizations based on accreditation decision categories and other related information. While the accreditation decision reflects the process for assessing an organization’s commitment to achieving continuous improvement in key areas of safety and quality, the Quality Report also reflects information about a hospital’s performance on National Patient Safety Goals, National Quality Improvement Goals for those hospitals reporting ORYX® chart abstracted performance measure data through a vendor, as well as certain special recognitions and achievements. Quality Check displays hospital performance on the National Quality Improvement Goal using individual measures which are updated quarterly, for the most recent rolling four quarters (12 months) of chart-abstracted data. Hospital performance at the individual measure level is displayed. The display includes that hospital’s observed rate of performance on each reported chart-abstracted measure through the use of various comparative symbols (plus, minus, check, or star), a display of the hospital’s performance against a target range of performance established using data received from all hospitals reporting on each measure, and a comparison of the hospital’s performance on each measure both on a nationwide and statewide level.

Quality Check™ can be accessed at http://www.qualitycheck.org to 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.

Pioneers in Quality

Pioneers in Quality™ is a Joint Commission program started in 2016 to assist hospitals on their journey toward electronic clinical quality measure (eCQM) adoption and reporting. Hospitals collect eCQM information through electronic health records (EHRs) and transmit the data to The Joint Commission (as part of its ORYX® performance measurement requirements) and to the Centers for Medicare & Medicaid Services (CMS). The Pioneers in Quality™ program provides resources to aid hospitals in the transition from chart-abstracted measures to eCQMs. Key components of the Pioneers in Quality™ program include regular educational webinars focused on eCQM adoption, Expert-to-Expert series webinars, a comprehensive eCQM resource portal and recognition for eCQM pioneers in America’s Hospitals: Improving Quality and Safety – The Joint Commission’s Annual Report.

Direct Data Submission Platform

The Joint Commission began accepting direct data submission of electronic clinical quality measure (eCQM) data from hospitals with the submission of calendar year (CY) 2017 eCQM data. The Direct Data Submission Platform enables an ORYX eCQM process that simplifies operations and reduces the burden for our accredited hospitals while ensuring regulatory compliance and security.

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.

CMS Hospital Inpatient Quality Reporting Program

The Hospital Inpatient Quality Reporting Program was originally mandated by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. This section of the MMA authorized CMS to pay hospitals that successfully report designated quality measures a higher annual update to their payment rates. Initially, the MMA provided for a 0.4 percentage point reduction in the annual market basket (the measure of inflation in costs of goods and services used by hospitals in treating Medicare patients) update for hospitals that did not successfully report. The Deficit Reduction Act of 2005 increased that reduction to 2.0 percentage points. This was modified by the American Recovery and Reinvestment Act of 2009 and the Affordable Care Act of 2010, which provided that beginning in fiscal year (FY) 2015, the reduction would be by one-quarter of such applicable annual payment rate update if all Hospital Inpatient Quality Reporting Program requirements are not met. Under the Hospital Inpatient Quality Reporting Program, CMS collects quality data from hospitals paid under the Inpatient Prospective Payment System, with the goal of driving quality improvement through measurement and transparency by publicly displaying data to help consumers make more informed decisions about their health care. It is also intended to encourage hospitals and clinicians to improve the quality and cost of inpatient care provided to all patients. The data collected through the program are available to consumers and providers on the Hospital Compare website at: https://www.medicare.gov/hospitalcompare/search.html. Data for selected measures are also used for paying a portion of hospitals based on the quality and efficiency of care, including the Hospital Value-Based Purchasing Program, Hospital-Acquired Condition Reduction Program, and Hospital Readmissions Reduction Program.

Hospital Value-Based Purchasing Program

Congress authorized the Inpatient Hospital VBP in Section 3001(a) of the Affordable Care Act. The program uses the hospital quality data reporting infrastructure that was developed for the Hospital Inpatient Quality Reporting (IQR) Program. The Hospital Value-Based Purchasing (VBP) program is part of CMS’s ongoing effort to structure Medicare’s payment system to reward providers for the quality of care they provide. This program adjusts payments to hospitals under the Inpatient Prospective Payment System (IPPS), based on the quality of care they deliver not just the quantity of services they provide. How hospitals perform on quality and resource use measures is linked to the IPPS. The IPPS makes up the largest share of Medicare spending, affecting payment for inpatient stays in approximately 3,000 hospitals across the country. The Hospital VBP Program is funded by reducing participating hospitals’ base operating Medicare severity diagnosis-related group (MS-DRG) payments by 2%. Any leftover funds are redistributed to hospitals based on their Total Performance Scores (TPS). What hospitals earn depends on the range and distribution of all eligible/participating hospitals’ TPS scores for a FY. It’s possible for a hospital to earn back a value-based incentive payment percentage that is less than, equal to, or more than the applicable reduction for that FY. The Hospital VBP Program is designed to promote better clinical outcomes for hospital patients, as well as improve their experience of care during hospital stays. Specifically, Hospital VBP seeks to encourage hospitals to improve the quality and safety of care that Medicare beneficiaries and all patients receive during acute-care inpatient stays by:
  • Eliminating or reducing the occurrence of adverse events (healthcare errors resulting in patient harm).
  • Adopting evidence-based care standards and protocols that result in the best outcomes for the most patients.
  • Re-engineering hospital processes that improve patients’ experience of care.
  • Increasing the transparency of care for consumers.
  • Recognizing hospitals that are involved in the provision of high-quality care at a lower cost to Medicare.

Electronic Clinical Quality Measures (eCQMs) Overview

Effective CY 2016, hospitals are required to electronically report clinical quality measures as a portion of the Hospital Inpatient Quality Reporting (IQR) and the Medicare EHR Incentive Programs. These quality measures were developed specifically to allow an electronic health record (EHR) system certified to the Office of the National Coordinator (ONC) standards to capture, export, calculate, and report the measure data. The CQMs required for reporting are electronically specified, using industry standards for the measure logic (Health Quality Measures Format [HQMF]) and the data transmission (Quality Reporting Document Architecture [QRDA]: Category I – patient-level data). As the industry updates these standards, CMS and ONC expect to reflect those updates in their respective requirements. Hospitals that successfully submit eCQM data to meet Hospital IQR Program requirements will also fulfill the Medicare EHR Incentive Program requirement for electronic reporting of CQMs with one submission. Eligible hospitals (EHs) are required to report eCQMs to the Hospital IQR Program. EHs and Critical Access Hospitals (CAHs) are required to electronically report to the Medicare EHR Incentive Program.

Introduction TJC
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Specifications Manual for Joint Commission National Quality Measures (v2019A1)
Discharges 10-01-19 through 12-31-19 (4Q19)


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