Background
In early 1999, the Joint Commission solicited input from a wide variety of stakeholders (e.g., clinical professionals, health care provider organizations, state hospital associations, health care consumers and convened a Pneumonia Advisory Panel about the potential focus areas for core measures for hospitals. In May 2001, the Joint Commission announced four initial core measurement areas for hospitals, which included acute myocardial infarction (AMI) and heart failure (HF), pregnancy (PR), and pneumonia (PN). The initial pneumonia measure set contained 5 measures (Oxygenation Assessment, Pneumococcal Screening and/or Vaccination, Blood Cultures, Smoking Cessation Advice/Counseling, and Antibiotic Timing). The implementation of two additional measures; Antibiotic Selection, and Influenza Vaccination were delayed until 7/1/2004.
Simultaneously, the Joint Commission worked with the Centers for Medicare & Medicaid Services (CMS) on the pneumonia measures that were common to both organizations. CMS and the Joint Commission worked together to align the measure specifications for use in the 7th Scope of Work and for Joint Commission accredited hospitals. Hospitals began collecting the initial 5 pneumonia measures for patient discharges beginning July 1, 2002.
In November of 2003, CMS and the Joint Commission began to work to precisely and completely align these common measures so that they are identical. This resulted in the creation of one common set of measure specifications documentation known as the Specifications Manual for National Hospital Quality Measures to be used by both organizations. The Manual contains common (i.e., identical) data dictionary, measure information forms, algorithms, etc. The goal is to minimize data collection efforts for these common measures and focus efforts on the use of data to improve the health care delivery process. Because the alignment effort resulted in one set of common pneumonia measures, in 2004, The Joint Commission Advisory Panel (TAP) and the CMS Technical Expert Panel (TEP) were merged into one panel and selected members of the Joint Commission PN TAP were appointed to the CMS PN TEP. A list of the current Pneumonia TEP membership is available.
The Joint Commission continues to collaborate with the Centers for Medicare and Medicaid Services (CMS) as well as the Infectious Disease Society of American (IDSA), the American Thoracic Society (ATS), the American Society of Emergency Room Physicians (ASEP), and the Centers for Disease Control and Prevention (CDC) with respect to the performance measures for patients with pneumonia.
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Important Information
Current Status of the antibiotic timing measures PN 5b and PN 5c
PN 5b Initial Antibiotic Receipt within 4 Hours of Hospital Arrival has been changed to reflect a 6 hour time frame. The new measure PN 5c Initial Antibiotic Receipt within 6 Hours of Hospital Arrival was implemented with 4/1/2007 discharges. In April 2007, NQF endorsement was removed from PN 5b (4 hour measure) and granted to PN 5c (6 hour measure). Due to the official standing of PN 5b as an RHQDAPU measure for fiscal years 2008 and 2009, the measure remains in the Specifications Manual for National Hospital Quality Measures and its calculation is still required. In terms of public reporting, the data for the 4 hour calculation (PN 5b) will be suppressed by both CMS and The Joint Commission after March 2008. Hospitals will continue to submit PN 5b until the IPPS rule can be altered through the rulemaking process. However, PN 5c will be calculated using PN 5b data, an action made possible by the fact that the data elements for both measures are exactly the same. Data will first be reported for PN 5c (6 hour measure) in March 2008 reflecting second quarter 2007 data. Thus, both PN 5b and PN 5c will be reported in March 2008. CMS has decided that PN 5c data to be previewed and reported on Hospital Compare can be suppressed by hospitals upon request until such time that the IPPS Rule can be changed through the rulemaking process to correctly name the NQF endorsed variant of the antibiotic timing measure for pneumonia inpatients.
Where to find the Pneumonia Core Measure Set
The Pneumonia measures can be found in the Specification Manual for National Hospital Quality Measures