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Joint Commission Hospital Requirements
The Joint Commission's ORYX ® initiative integrates outcomes and performance measurement data into the accreditation process. Beginning in July 2002, hospitals accredited by Joint Commission were required to begin collecting and submitting data on standardized - or "core" - performance measures. The initial four "core measure" sets are:
- Acute myocardial infarction
- Heart failure
- Community acquired pneumonia
- Pregnancy and related conditions
(including newborn and maternal care)
Beginning in July 2004, a fifth
core measure, Surgical Infection Prevention, was
added.
Working with the Centers for Medicare and Medicaid
Services (CMS) and the National Quality Forum
to provide consistency in reporting core performance
measures, it is possible for hospitals to select
core measures that meet both CMS and Joint Commission
requirements.
Hospitals are required to select core measures
based on services provided. If the hospital does
not perform any services specific to any of the
core measures, it will select non-core measures
"from their listed performance measurement system(s)
that has met JCAHO's initial requirements for
inclusion in the accreditation process and has
signed contracts with JCAHO." One such system
is the SOIX Outcomes Monitoring System (OMS).
Hospitals formally select core measure sets based
on health care services they provide:
If the hospital serves patient populations with
conditions that correspond with two or more core
measure sets, the hospital should select two of
the initial four sets and submit data via their
selected measurement system. The hospital will
no longer be required to collect and transmit
data on their non-core measures.
Beginning in January 2004, hospitals are required
to report data on a total of three core measure
sets (to the extent possible based on services
provided). For a complete breakdown of ORYX requirements
for 2004, see General ORYX requirements
for hospitals at
http://www.jcaho.org/accredited+organizations/hospitals/oryx/index.htm.
Small hospitals, having an average
daily census of 10 or less, are required to collect
data internally on all applicable measures, but
are exempt from having to submit the data to the
Joint Commission. However, they must provide reports
of their quarterly analysis of data to surveyors
during on-site surveys. Surveyors will want to
assess the hospital's use of their outcome measures
in their performance improvement activities.
For more information about Core Measures, go to
http://www.jcaho.org/pms/core+measures/index.htm.
For information about how SOIX can
help you report Core Meassures, please CONTACT
US: Mailing Address:
800 E. Leigh St., Suite 206-5, Richmond, Virginia
23219-1598
Toll Free Phone: 877.602.0156
Fax: 804-740-9401
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