The standards for Performance Measurement and Improvement focus on four key areas:
- Creating an organized comprehensive approach to performance improvement
- Utilizing comparative data to evaluate program processes and patient outcomes
- Evaluating participants’ perception of care quality, and
- Maintaining data quality and integrity
The performance measurement requirements for Disease-Specific Care (DSC) Certification programs comprise two stages:
Stage I – Non-Standardized Measures: DSC certification programs and services are required to collect and analyze data on 4 or more performance measures. At least 2 of the 4 should be clinical measures related to or identified in clinical practice guidelines for that program or service. Measures selected by the program or service should be evidence-based, relevant, valid and reliable. The Joint Commission is not prescriptive during Stage I regarding the specific measures that are implemented; the emphasis is on the use of performance measures for improving care.
Stage II – Standardized Measures: Standardized performance measures have precisely defined specifications, standardized data collection protocols, meet established evaluation criteria and can be uniformly adopted for use. Standardized sets of measures are identified and specified by The Joint Commission and external performance measurement experts. When available, standardized measures replace non-standardized measures and are uniformly adopted by all certified programs, as well as programs seeking initial certification. Currently, standardized measures are available for Primary Stroke Center certification.
Performance Measurement Requirements for DSC Certification
The standards require the DSC program to demonstrate that it:
- Routinely applies the cycle for performance improvement to identify and address improvement opportunities
- Implements a plan for improvement and graphically depicts measurement results over time to demonstrate improvement in the measured areas
- Reports data to The Joint Commission
- Reviews the effectiveness of the interventions implemented in response to improvement opportunities identified by the measurement activity
Effective July 1, 2007, specific performance measurement requirements will be implemented for all certified programs which include:
- Collection of monthly data points for both standardized and non-standardized measures
- Prior to initial certification, collection of a minimum of 4 months of performance measure data for each standardized and/or non-standardized measure submitted at the time of application
An additional performance measurement requirement for standardized measure data reporting is anticipated in 2008, following enhancements to The Joint Commission Connect™ which will afford certified programs the capability for electronic data submission. Currently, DSC certified programs collect data quarterly and report data to The Joint Commission at the time of the intra-cycle review and recertification. Under the new requirement, certified programs will electronically report monthly data points for standardized measures to The Joint Commission each quarter. The Joint Commission will aggregate the data submitted electronically and return it to certified organizations for comparative performance evaluation.
Performance Measurement for Disease-Specific Care Certification
Asthma
Heart Failure
Stroke
Lung Volume Reduction Surgery