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  The Joint Commission Expands Performance Measurement Requirements for General Medical/Surgical Hospitals

(OAKBROOK TERRACE, Ill. – November 30, 2012) The Joint Commission today announced that it will expand performance measurement requirements for accredited general medical/surgical hospitals from four to six core measure sets. The additional requirements, which are part of The Joint Commission’s ORYX® performance measurement initiative to stimulate and guide quality improvement efforts, will take effect January 1, 2014.

Four of the six measure sets will be mandatory for all general medical/surgical hospitals that serve specific patient populations addressed by the measure sets and related measures. The measure sets address acute myocardial infarction (AMI), heart failure, pneumonia and the Surgical Care Improvement Project (SCIP). These core measure sets are common to several federally legislated programs and selected most frequently by hospitals.

For hospitals with 1,100 or more births per year, the perinatal care measure set will become the mandatory fifth measure set. The Joint Commission chose the perinatal care measure set because of the high volume of births in the United States (four million per year) and because it affects a significant portion of accredited hospitals. The Joint Commission will monitor the threshold of 1,100 births over the first four to eight quarters of data collection to reassess ongoing applicability. The Joint Commission expects that this threshold will be modified over time so that more hospitals are included and strongly encourages hospitals to consider adopting this measure set before the required effective date of January 1, 2014.

The 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. 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. The Joint Commission expects that requirements will increase over time, depending on the national health care environment, emerging national measurement priorities and hospitals’ ever-increasing capability to electronically capture and transmit data.

Although hospitals must modify and update measure set selections two months before the start of data collection on January 1, 2014, 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 (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.

For more information about the expanded performance measurement requirements for general medical/surgical hospitals, please contact Frank Zibrat, associate director, Accreditation Systems Integration and ORYX, The Joint Commission, at or 630-792-5992. ORYX vendors may direct questions to Mary Kay Bowie, B.S.N., M.H.S.A., R.N., CPHQ, associate director, Center for Measurement System Operations, The Joint Commission, at or 630-792-5974. For more information about performance measurement and accreditation, please visit


Founded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission evaluates and accredits more than 19,000 health care organizations and programs in the United States, including more than 10,300 hospitals and home care organizations, and more than 6,500 other health care organizations that provide long term care, behavioral health care, laboratory and ambulatory care services. The Joint Commission currently certifies more than 2,000 disease-specific care programs, focused on the care of patients with chronic illnesses such as stroke, joint replacement, stroke rehabilitation, heart failure and many others. The Joint Commission also provides health care staffing services certification for more than 750 staffing offices. An independent, not-for-profit organization, The Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care. Learn more about The Joint Commission at



Core Measure Sets

About ORYX

Performance Measurement Initiatives

About The Joint Commission

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Elizabeth Eaken Zhani
Media Relations Manager
The Joint Commission

Bret Coons
Media Relations Specialist
The Joint Commission