Joint Commission Announces Greater
Flexibility in Measure Reporting for 2015
The Joint Commission continually assesses how measure
reporting requirements can help accredited organizations
improve their performance as part of its objective to drive
health care improvement through measurement. This
ongoing assessment has most recently resulted in The Joint
Commission’s decision to provide accredited hospitals
with greater flexibility in meeting ORYX® performance
measurement requirements beginning with measure set
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selections for 2015.
At the beginning of 2014, The Joint Commission
increased reporting requirements to six sets of core measures
comprising mandatory as well as discretionary measure
sets (see November 2013 Perspectives, page 11). The Joint
Commission will maintain the current requirements for
reporting on six sets of measures; however, hospitals will
Joint Commission Perspectives®, December 2014, Volume 34, Issue 12
Copyright 2014 The Joint Commission
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Joint Commission Announces Greater Flexibility in Measure Reporting for 2015
(continued)
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Standard PI.02.01.03
The Joint Commission has determined that the following
requirements—Standard PI.02.01.03 and element of
performance (EP) 1—are not in effect during 2015:
PI.02.01.03: The hospital improves its performance on
ORYX® accountability measures.
EP 1: The hospital achieves a composite performance rate
of at least 85% on the ORYX® accountability measures
transmitted to The Joint Commission.
no longer be required to report on four sets of mandatory
measures (that is, acute myocardial infarction, heart failure,
pneumonia, surgical care improvement project). Perinatal care
is the only measure set that will remain mandatory in 2015—
and it will be mandatory only for those hospitals with at least
1,100 live births per year. Otherwise, hospitals will be able
to make their measure set selections from the complement of
core measure sets.
In addition, effective with data collection beginning
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January 1, 2015, accredited hospitals will have the flexibility
of meeting ORYX reporting requirements through one of the
following three options:
l Option 1: Vendor submission of quarterly data on six (6)
sets of twelve (12) chart-abstracted measures
l Option 2: Vendor submission of quarterly data on six (6)
sets of seven (7) electronic clinical quality measures
(eCQMs)
l Option 3: Vendor submission of quarterly data on six (6)
measure sets using a combination of chart-abstracted
measures and eCQMs
Please note that this change will result in the temporary
suspension of Performance Improvement (PI) Standard
PI.02.01.03 during 2015 (shown in the box on this page).
Because organizations will be able to submit measures using
various submission methods—that is, chart-based measure
data, eCQMs, or a combination of both—those data can no
longer be viewed as having the same level of comparability
Joint Commission Perspectives®, December 2014, Volume 34, Issue 12
Copyright 2014 The Joint Commission
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Joint Commission Announces Greater Flexibility in Measure Reporting for 2015
(continued)
Continued from page 4
as they did in 2014. As such, it is not possible to accurately
calculate the composite rate with the degree of assurance
necessary to apply the PI standard. This standard is expected
to be reinstated at a future date to be determined.
These options, which allow The Joint Commission to
more closely align its measurement requirements for 2015
with those of the Centers for Medicare & Medicaid Services
(CMS), may also be viewed in full on The Joint Commission’s
website at http://www.jointcommission.org/assets/1/18/2015_
OPTIONS_UPDATED_11-4_15.pdf.
Advanced Certification in
Heart Failure
Effective with January 1, 2015 discharges, hospitals that
maintain Joint Commission Advanced Certification in Heart
Failure (ACHF) will no longer be required to report on
the following two heart failure measures, HF-2 (Evaluation
of LVS Function) and HF-3 (ACEI or ARB for LVSD).
Performance measure reporting requirements will continue
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Advanced Stroke Certification
Measures
Hospitals seeking (or that have already achieved) Primary
Stroke Center (PSC) Certification must continue to report on
the existing mandatory eight (8) chart-abstracted measures.
Hospitals seeking (or that have already achieved) Comprehensive Stroke Center (CSC) Certification must continue
to report data on the existing mandatory (8) eight chartabstracted measures as well as data on eight (8) new CSC
measures effective with January 1, 2015, discharges.
to be met through reporting on the six mandatory inpatient
advanced certification for heart failure (ACHF) measures that
were required effective January 1, 2014.
Questions about ORYX core measure reporting
requirements and measure set selections may be directed
to Frank Zibrat, associate director, Accreditation Systems
Integration and ORYX, The Joint Commission, at fzibrat@
jointcommission.org or 630-792-5992. P
Joint Commission Perspectives®, December 2014, Volume 34, Issue 12
Copyright 2014 The Joint Commission