CMS and JCAHO quality measures now are the same: Will that save you time?

It may reduce redundant data collection, but quality managers have concerns

Are you tired of dealing with multiple data definitions and similar but differing performance measures? You’ve probably wished many times that the quality measures from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare & Medicaid Services (CMS) were identical.

In an effort to reduce your data collection burdens, the two organizations have agreed to work together to completely align current and future hospital quality measures in their condition-specific performance measure sets, including the Joint Commission’s ORYX core measures and CMS 7th Scope of Work Quality of Care Measures on heart attack, heart failure, pneumonia, and surgical infection prevention.

The measure alignment will make it easier and less expensive for hospitals to comply with existing requirements for data collection and reporting, says Sharon Sprenger, project director for the group on performance measures in the Joint Commission’s division of research. "You don’t want it to be so burdensome that people don’t have time to use the data to make improvements," she adds.

The decision sends a positive message that JCAHO and CMS are working in a collaborative manner to improve the quality of care for these patient populations, says Barbara Wilkins, RN, performance improvement coordinator at Danville (VA) Regional Medical Center.

"This is definitely good news for quality professionals," she says. "I think it’s a wonderful thing. Now when we collect data, it meets both agencies’ requirements. It reduces duplication of efforts and decreases confusion when we report data to various committees."

Overall, standardizing data definitions will have a positive effect on the care patients receive, predicts Catherine M. Fay, RN, director of performance improvement at Paradise Valley Hospital in National City, CA. "It has been a long time in coming and a very positive step," she says. "There has been a sense of serving two masters. The measures are evidence-based, and as such, it has been difficult to clarify to health care staff why the two organizations have selected different measures on which to focus."

Quality professionals responsible for data collection activities would frequently ask JCAHO for identical measures, Sprenger reports.

"At presentations, we would hear from them, Why can’t you guys get together and have the same specifications?’" she says. "That certainly was an important impetus. We understood that it is difficult to have one set of specifications from CMS and another from JCAHO."

The measures in the four Joint Commission and CMS hospital measure sets currently calculate the same way, but there are differences in the format of the specifications for data elements, types of cases excluded, calculation algorithms, and other measure dimensions, Sprenger explains.

Although the change may seem sudden, JCAHO actually has been working with CMS to align the measures they have in common since May 2001 when JCAHO announced its four initial core measures including acute myocardial infarction, heart failure, and pneumonia, Sprenger notes.

"So when hospitals began collecting data in July 2002, we had worked with CMS on these measures that were common to both organizations. We were close, but we were not exact," she says. For example, one measure included only one data element for JCAHO, but CMS had four data elements for the same measure.

Also, although measures were calculated the same way, the data elements might have differed, or definitions might have been slightly different.

"What we have done now is to completely identify with one another in our measures," she says. "The measures we do have in common have the exact same definition."

Part of the goal was to reduce the data collection burden for quality managers, Sprenger notes. "It will help to decrease some of that duplication of efforts, where previously individuals were looking at different measures and trying to figure out how they were the same. We also have a commitment that we stay aligned moving forward for any future change to these measures or subsequent measures."

"It is reassuring that their joint effort is at the practice level now, where the data collection occurs," says Janet A. Brown, RN, BSN, BA, CPHQ, FNAHQ, president of JB Quality Solu-tions Inc., a Pasadena, CA-based consulting firm. "Any time those with separate and sometimes disparate regulatory control and decision-making authority can come to a consensus, it is a time for rejoicing among quality professionals and all who seek to comply," she explains.

Many quality managers have high hopes for a significant time savings in data collection activities. "Right now, we have two separate processes for data collection for CMS and JCAHO. You have to do it differently for each agency," says Missi Halvorsen, RN, BSN, senior consultant for JCAHO/regulatory accreditation at Baptist Health in Jacksonville, FL. "It’s always been frustrating, and I think it is a good idea for them to align the measures."

At many organizations, data collection still is a largely manual process, notes Halvorsen. "If you are in a paperless environment and can pull that information electronically, that’s one thing. But if you’re half and half or all paper, it’s still a manual process and very time-consuming," she says.

Although the organization can access some data electronically through pharmacy billing, other things, such as smoking cessation counseling, still require going through paper charts to see if they were done, she explains.

Despite the initial time savings, Halvorsen is leery of a possible hidden agenda of JCAHO and CMS — that of linking reimbursement with outcomes. "One concern I do have is that this is one step toward basing reimbursement on our outcomes measures, which is currently the case with long-term care facilities such as nursing homes," she says.

Other quality professionals point to the inevi-tability of additional measures in the near future, which would negate any time savings as a result of the alignment. Wendy H. Solberg, CHE, director of quality resources at Gwinnett Hospital System in Lawrenceville, GA, says she doesn’t expect any true savings of resources over the long term.

"We have already been collecting all these measures and working through our multidisciplinary team process to improve processes," she explains. "Also, we anticipate another core measure eventually, which will simply add to the data abstraction."

In July 2004, hospitals began collecting additional core measure data on surgical infection prevention. JCAHO is actively developing new measure sets that address the intensive care unit, pain management, and inpatient pediatric asthma.

Although data for all the measures for both CMS and JCAHO already are being collected at Gwinnett, the alignment of the quality measures will simplify data reporting and transmission, says Solberg. "This is a great benefit to us. Having them aligned will streamline our processes and enhance the understanding of what each group is reporting."

Single manual is key

CMS and JCAHO have jointly released and made available on their web sites a common measures specification manual, which includes a data dictionary, measure information forms, algorithms, and other technical support information. (For more information, see editor’s note at the end of this article.)

The intent is to ensure that measures common to both CMS and JCAHO are completely identical by the time data collection for January patient discharges begins, according to Andy Kubilius, project director for database and technical aspects of the ORYX measures.

Having a single specifications manual for both organizations will have a dramatic affect on quality professionals, says Kubilius. "This is key, since prior to this alignment, we had different specifications manuals," he says.

Currently, there is considerable confusion without standardized data definitions and collection specifications, Brown says. For example, one large community hospital struggles to meet the pneumonia core measure related to timely antibiotic initiation because of patients in transitional care, or patients transferred from transitional care to acute. "It is my understanding that currently some hospitals include transitional care patients in reporting pneumonia data, and some do not," she adds.

Having clear standardized specifications, including inclusions and exclusions for common data definitions, will make data collection more reliable over time and, therefore, a fairer playing field for public national comparative reporting and for use in accreditation decisions, Brown says.

The manual includes all measures for both organizations, even those that aren’t common. For instance, in the acute myocardial infarction data set, JCAHO has an inpatient mortality measure and CMS doesn’t, while CMS has two test measures for lipids that JCAHO is not using. "The pregnancy and related conditions measure set that CMS doesn’t have is also in the manual," Sprenger adds. The manuals, which were created jointly by JCAHO and CMS, include specific instruction and guidance for data collection, she explains. "This will hopefully give them more detailed instruction to make their data collection more efficient, or if there is a particular data element they are having some issues with, to give them more guidance."

Something else that will help reduce the data collection burden involves sampling of the patient populations, Kubilius adds. "Both CMS and JCAHO allowed for sampling of the patient population, but again, we had different sampling protocols. CMS was sampling all Medicare patients, and we were sampling all patients."

JCAHO and CMS worked to create the same sampling methodology and worked with the same number of cases for the manual, he explains. "In our case, we decreased the sample size. This will be a big help to larger organizations, although not as big an impact on smaller hospitals, since whenever you are sampling, you want a representative population, and their number may be such that they do need to take all cases because the number is so small."

A central data dictionary now contains all the different data definitions, Kubilius says.

"Previously, CMS had multiple manuals by topic area, so obviously keeping track of that was a little more complicated. Now anyone wanting to meet the CMS requirements goes to one manual and one data dictionary," he adds.

[For more information, contact:

Janet A. Brown, RN, BSN, BA, CPHQ, FNAHQ, JB Quality Solutions Inc., 2309 Paloma St., Pasa-dena, CA 91104-4926. Phone: (626) 797-3074. Fax: (626) 797-3864. E-mail:

Catherine M. Fay, RN, Director of Performance Improvement, Paradise Valley Hospital, 2400 E. Fourth St., National City, CA 91950. Phone: (619) 470-4263. Fax: (619) 470-4162. E-mail:

Missi Halvorsen, RN, BSN, Senior Consultant, JCAHO/Regulatory Accreditation, Baptist Health, 1325 San Marco Blvd., Suite #601, Jacksonville, FL 32207. Phone: (904) 202-4966. Fax: (904) 334-7628. E-mail:

Wendy H. Solberg, CHE, Director of Quality Resources, Gwinnett Hospital System, 1000 Medical Center Blvd, Lawrenceville, GA 30045. Phone: (678) 442-3439. Fax: (770) 682-2247. E-mail:

Barbara Wilkins, RN, Performance Improvement Coordinator, Danville Regional Medical Center, 142 S. Main St., Danville, VA 24541. Phone: (434) 799-2281. E-mail:

To access the specification manual, go to Under "Joint Commission and CMS Announce Aligned Manual for Hospital Quality Measures," click on "See manual," "Download the Specifications Manual for National Hospital Quality Measures, version 1.0 (effective for 1/1/2005 discharges)."]