TJC expands core measure sets

One mandated, one choice

On Jan. 1, 2014, The Joint Commission will start holding accredited hospitals responsible for two more core measure sets. Four of the six will be mandatory for all hospitals that serve populations addressed by them and their related measures — those for acute myocardial infarction, heart failure, pneumonia, and the Surgical Care Improvement Project. The two new ones are for hospitals that meet specific criteria.

Hospitals that have at least 1,100 births per year will have a fifth mandatory set. That threshold may change after a year or two of evaluation. If anything, it is likely to be lowered so that more hospitals will be included. Even if it’s not required for your hospital, TJC suggests adopting the measure.

The last measure requires all hospitals to choose something from an approved list of potential measures. They are: asthma care for children, emergency department care, hospital-based inpatient psychiatric services, hospital outpatients, immunization, tobacco treatment, stroke, substance use, and venous thromboembolism.

Hospitals are required to modify and update measure set selections two months before the start of data collection on Jan. 1, 2014, but “data received for the newly added measure sets and measures will not be incorporated into calculations for either Performance Improvement (PI) Standard PI.02.01.03 ... 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,” according to a Joint Commission news release.

The new measures don’t apply to critical access or specialty hospitals.