The hospital selects and uses performance measures from among those available that are releva...

(1)

The hospital selects and uses measures that are relevant to the hospital.

(2)

The hospital selects and uses measures that support strategic measurement goals.

(3)

The hospital selects and uses measures that target high-volume, high-risk, problem-prone issues.

(4)

The hospital selects and uses measures that provide opportunities to improve the quality of care.

(5)

The hospital selects chart-abstracted measures and/or electronic clinical quality measures (eCQMs) based on its patient population/services offered to meet current ORYX® requirements.

(6)

The hospital selects performance measures within Joint Commission’s data submission application.

(7)

The hospital discusses with the surveyor how the data are used to identify, prioritize, and monitor performance improvement activities.

(8)

The hospital uses each individual measure to identify patterns, trends, or variations for improvement opportunities before replacing it. (For example, chart-abstracted measures should begin the first quarter of the calendar year or first quarter following receipt of an accreditation decision letter and be used for the remainder of the calendar year before replacing any measures.)

(9)

Based on Joint Commission statistical analysis, the hospital continues to use a measure if the data suggest an unstable pattern of performance or otherwise identify an opportunity for improvement.

(10)

The hospital selects a new measure if the data reflect stable and satisfactory performance.

(11)

The hospital notifies Joint Commission of a change in its service line that results in specific measures no longer being applicable (for example, a hospital closes its obstetrical unit and can no longer report the Perinatal Care measures).

(12)

The hospital’s performance measure data are submitted to Joint Commission in the timelines established and technical manner prescribed by Joint Commission.

(13)

The hospital resolves data quality issues for reported performance measures.

(14)

For the most recent 12-month calendar reporting period, the hospital achieves and sustains an acceptable level of performance for each measure, as defined by Joint Commission statistical analysis, before it discontinues a measure's use in performance improvement activities.