Additional measures sets to be chosen by hospitals

The Joint Commission’s (TJC’s) sixth measure set (or fifth and sixth measure sets, for hospitals with fewer than 1,100 births per year) will be chosen by all general medical/surgical hospitals from the approved complement of core measure sets, according to TJC.

These sets are related to children’s asthma care, emergency department care, hospital-based inpatient psychiatric services, hospital outpatients, immunization, tobacco treatment, stroke, substance use, and venous thromboembolism. TJC expects that requirements will increase over time, depending on the national healthcare environment, emerging national measurement priorities, and hospitals’ ever-increasing capability to electronically capture and transmit data.

Hospitals must modify and update measure set selections two months before the start of data collection on Jan. 1, 2014. However, data received for the newly added measure sets and measures will not be incorporated into calculations for Performance Improvement (PI) Standard PI.02.01.03, which requires that the hospital improve its performance on ORYX accountability measures, or the Top Performers on Key Quality Measures program until sufficient data are received. This will provide hospitals a minimum of 12 months and up to 23 months of experience with the new measure sets before the data are included in performance calculations.

Performance measurement requirements for critical access hospitals and specialty hospitals, such as children’s hospitals and psychiatric hospitals, will continue as currently defined until other applicable metrics are identified and implemented.