The Joint Commission to Add 2 Medical/Surgical Hospital Requirements

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The Joint Commission announced it will expand performance measurement requirements for accredited general medical/surgical hospitals from four to six core measure sets, effective Jan. 1, 2014.

The additional requirements are part of The Joint Commission's ORYX performance measurement initiative to stimulate and guide quality improvement efforts.

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The four current measure sets required for general medical/surgical hospitals include acute myocardial infarction, heart failure, pneumonia and the Surgical Care Improvement Project.

The new fifth measure set, the perinatal care measure set, will be required for hospitals with at least 1,100 births per year. The new sixth measure set (or fifth and sixth measure sets for hospitals with fewer than 1,100 births per year) will be chosen by general medical/surgical hospitals from the approved list of core measure sets, which include children's asthma care, emergency department care, hospital-based inpatient psychiatric services, hospital outpatients, immunization, tobacco treatment, stroke, substance use and venous thromboembolism.

Hospitals must modify and update measure set selections two months before data collection begins Jan. 1, 2014. However, data for the new measure sets will not be used in calculating Performance Improvement Standard PI.02.01.03 or the Top Performers on Key Quality Measures program until sufficient data are received, according to the release. This provision will enable hospitals between 12 and 23 months to gain experience with the new measure sets before the data are incorporated in performance calculations.

Critical access hospitals and specialty hospitals, such as children's hospitals and psychiatric hospitals, will continue to follow current performance measurement requirements.

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