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– PERFORMANCE MEASURES –
JCAHO – Joint Commission
for Accreditation of Healthcare Organizations

logo forJoint Commission for Accreditation of Healthcare OrganizationsThe Joint Commission is an accrediting agency with quasi-regulatory powers in some States that has become a major force addressing and implementing performance measures across healthcare organizations.

Standardized metrics called ‘core measures’ have been developed, often in collaboration with other organizations, and they have been approved by the NQF. Thousands of other non-standardized ‘non-core measures’ have also been implemented via the ORYX® initiative, thereby permitting JCAHO to integrate outcomes, core’ and non-core’ performance measures, and other performance measurement data into the accreditation process.

Through 2006, JCAHO has identified five core performance measure sets for hospitals, including acute coronary syndrome/ acute myocardial infarction, heart failure, pneumonia, pregnancy and related conditions, and surgical infection prevention (SIP). ICU, pain management, children's asthma care and hospital-based inpatient-psychiatric services measures are scheduled to follow.

In September 2004, the Joint Commission and the Centers for Medicare and Medicaid Services (CMS) announced that they are working together for precise alignment of current and future measures common to both organizations. These measures include 4 of the 5 JCAHO core performance measure sets that are also the measures used by the Hospital Quality Alliance (HQA) that has been driven by the American Hospital Association (AHA), the Federation of American Hospitals (FAH), and the Association of American Medical Colleges (AAMC). These standardized common process measures are now referred to as "Hospital Quality Measures" [PDF] that in 2006 include:

  • •  Acute myocardial infarction (AMI) – 8 measures
  • •  Heart failure (HF) – 4 measures
  • •  Pneumonia (PN) – 7 measures
  • •  Surgical infection prevention (SIP) – 2 measures
  • •  HCAHPS – 1 measure (2007) (An additional HCAHPS measure, the patient perspectives on hospital care survey, is expected to be available for public reporting in 2007.)

Facility-identified performance for these common measures are published by CMS at Hospital Compare®. Therefore, 4 of JCAHO's 5 ‘core measures’ are integrated with CMS and the HCA initiative.

JCAHO's remaining core performance measure set that are not integrated with CMS includes the Oryx® measures for Pregnancy and related (PR) conditions [PDF, p37].

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