The following communication guidelines have been developed by The Joint Commission to direct performance measurement systems in appropriately referencing The Joint Commission and portraying this relationship in the most credible and accurate manner. Any questions about these guidelines should be directed to Denise Tucker, the Professional Relations and Speakers Bureau Coordinator, at (630) 792-5633.
Note: No performance measurement system is considered acceptable for use in meeting accreditation requirements until the system executes a Performance Measurement System Agreement with The Joint Commission.
Information about the new Joint Commission brand
In early January 2007, the Joint Commission refreshed its brand visual identity (name and logo) in support of its continuing efforts to improve the value of accreditation and its utility as a mechanism for improving the quality and safety of patient care. The Joint Commission on Accreditation of Healthcare Organizations shortened its name to The Joint Commission. The move to a shorter name is intended to both make the name more memorable and reflect current common practice. The Joint Commission commissioned a design firm to create a refreshed logo and Visual Identity System for the organization and its affiliate JCR. The new identity is reflected in:
- Redesigned website at www.jointcommission.org.
- Redesigned Gold Seal™ with the new logo.
- New tagline: Helping health care organizations help patients.
- The “Jayco” extranet website was renamed “Joint Commission Connect™.”
With the implementation of The Joint Commission’s new brand and name in January 2007, the previous acronym “JCAHO” should not be used. It is no longer applicable. It is permissible for external parties, including performance measurement systems, to use the initialism “TJC.”
Guidelines for candidate performance measurement systems
Candidate performance measurement systems are those systems that have signed The Joint Commission’s Participation Agreement and are being evaluated by The Joint Commission. A system remains a candidate until The Joint Commission renders its final decision and subsequently executes a signed Performance Measurement System Agreement with the candidate system.
- Candidate systems should use the following language for promotional and publicity purposes: “[Measurement system name] is being considered by The Joint Commission for possible inclusion in the ORYX® initiative for purposes of participating in the accreditation process.”
- Candidate systems may not use The Joint Commission logo for publicity or promotional purposes.
Guidelines for performance measurement systems that have been accepted or listed for inclusion in the accreditation process
- For publicity or promotional purposes, it is correct to say that a performance measurement system has met the criteria for inclusion in the accreditation process and is included on The Joint Commission’s list of acceptable systems. [Measurement system name] is committed to meeting future criteria established by The Joint Commission. Accepted measurement systems must include this information in all marketing and promotional materials that refer to the inclusion of a system for purposes of participating in The Joint Commission’s accreditation process. It is not accurate to state that The Joint Commission has “approved” or “accredited” an individual performance measurement system.
- A system may promote or publicize that it has met the criteria for inclusion in the accreditation process as defined previously once The Joint Commission has executed a Performance Measurement System Agreement from the system.
- The system is required to inform customers and clients of any system status changes initiated by The Joint Commission, such as moving from “fully listed status” to “provisionally listed” or “contractual noncompliance” and/or a required audit intervention status.
- Regarding measures that have been submitted to The Joint Commission by listed performance measurement systems for review and have been deemed acceptable for use in the accreditation process, it is correct for systems to state that the following [number] measures have been accepted by The Joint Commission for accreditation purposes in connection with the ORYX® initiative.
- “ORYX” is a registered trademark of The Joint Commission, so the symbol ® should be used after ORYX in all titles or headlines and the first time the word appears in any text. Performance measurement systems may not use the name “ORYX” in the names of their products or services.
- Use of The Joint Commission logo is permitted and encouraged, provided that systems adhere to the following guidelines:
- The Joint Commission logo includes the name and symbol. Do not change the format of the logo. The name and words may not be separated from the symbol and they must be printed in the same color. In four-color process printing, the logo uses PMS 7407 (gold) and PMS 2747 (blue).
- The typeface, name and/or symbol may not be manipulated or modified in any way.
- The Joint Commission logo must not be printed larger than the performance measurement system’s logo.
- The Joint Commission logo may not be used in any way that may suggest to the reader that the product or service offered by the system is a Joint Commission product or service.
- Do not add graphic devices to The Joint Commission logo such as seals or other words or slogans.
- The guidelines for printing the logo apply for use on all print materials.
For more information about the logo or to obtain logos, contact Denise Tucker, the Professional Relations and Speakers Bureau Coordinator, at (630) 792-5633.
Guidelines for performance measurement systems that have attempted or successfully completed the transmission of trial data
Performance measurement systems are prohibited from publicly stating their status as it relates to the trial transmission of either health care organization specific and/or comparative data until they have been notified in writing by The Joint Commission that they have been successful in transmitting all required data sets.
- Upon successful trial transmission of either health care organization specific and/or comparative data, the following language should be used: “[Measurement system name] has successfully trial transmitted ORYX® test data to The Joint Commission.”
Guidelines for performance measurement systems that have attempted or completed the transmission of production data
- Performance measurement systems are prohibited from publicly stating their status regarding a production data transmission of either health care organization specific and/or comparative data until they have obtained at least one X12 verification report from The Joint Commission’s extranet for the quarter being addressed (see the ORYX® Aggregate Data Implementation Guide for further information). A X12 verification report provides information regarding the attempted transmission of production data to The Joint Commission. This report does not ensure the quality or completeness of the data. Therefore, in this situation, the following language should be used: “[Measurement system name] is in the process of transmitting [core/non-core] production data for [name quarter(s)] to The Joint Commission.”
- After the data transmission deadline for each quarter [see transmission schedule], if at a minimum one X12 verification report denotes that some of the data were successfully received, the following language should be used: “[Measurement system name] has transmitted [core/non-core] production data for [name quarter(s)] to The Joint Commission.” It is very important that systems not make reference to the transmission being “successful” or “complete” since this inappropriately connotes that the quality of the data has been fully reviewed and is error free.
Audit communication guidelines for listed performance measurement systems
For the purposes of these communication guidelines, “audit” refers to the period of time that begins with The Joint Commission’s notification to the measurement system that it has been scheduled for an audit intervention and ends with the release of a written report to the measurement system indicating completion of all audit-related processes (see the Joint Commission’s 2008 ORYX® Performance Measurement System Audit Plan). The following are communication guidelines for performance measurement systems in various stages of the audit process.
- Once the measurement system is notified of an audit status, the performance measurement system’s noncompliance and audit intervention status will be displayed on the ORYX® Systems List on The Joint Commission’s website. This notation will remain in place until the system has received official notification from The Joint Commission noting compliance with all current criteria. For those performance measurement systems in the audit process (as defined above), the following language should be used: “The audit of [measurement system name] is in progress and results are pending.”
- For those performance measurement systems that have completed all audit-related processes and have received official notification from The Joint Commission noting compliance with all current criteria, the system can use the following language: “[Measurement system name] has been audited by The Joint Commission on [the date] and was found to be in compliance with all required criteria evaluated on [the date].” Additionally, the performance measurement system’s noncompliance and audit intervention status will be removed from the systems list on The Joint Commission’s website.
- For those performance measurement systems that have completed all audit-related processes and were not found to be in compliance with all required criteria, and the process for removing the system from the list of systems has been initiated, the system can use the following language:
“[Measurement system name] was audited by The Joint Commission on [the date] and was not found to be in compliance with all required criteria evaluated on [the date].” Once the performance measurement system has received official notice of The Joint Commission’s intent to remove the system from the ORYX® listed systems, the system may provide details of its deficiencies as it deems appropriate. In addition, the system is required to inform customers or clients that the process for removing the system from the accepted list has been initiated by The Joint Commission.
- Performance measurement systems referencing a Joint Commission audit must refer to the findings of the most recent audit conducted.
Guidelines for performance measurement systems that have executed a legally binding agreement to participate in the ORYX® core measurement initiative
A performance measurement system that has executed a legally binding agreement to embed a set or sets of ORYX core measures should use the following language, depending on the system’s status within the core measure process.
- For those systems that have signed a legally binding contract rider with The Joint Commission expressing their commitment to embed core measures, the following language should be used: “[Measurement system name] has signed a legally binding agreement with The Joint Commission expressing its commitment to embed the following ORYX® [insert-specific accreditation program – e.g., hospital] core measure sets: [insert core measure set name(s)].”
- For those systems that have successfully completed verification for a core measure set or sets, the following language should be used: “[Measurement system name] has successfully met the technical requirements and is approved to transmit data for the following ORYX® [insert specific accreditation program – e.g., hospital] core measure sets: [insert core measure set name(s)].”
Note: The Joint Commission will regularly update this level of information (i.e., legally binding commitment and measure set approval) on our website. A system’s specific status as it relates to the verification process will not be posted.
Guidelines for core performance measurement systems utilizing a subcontractor
Any listed core performance measurement system that has subcontracted on an ongoing basis, one or more important functions, must make that subcontracting arrangement known to its actual and prospective clients with which it is in communication, as well as to The Joint Commission.
Guidelines for core performance measurement systems for the use of aggregate core comparison data
For those systems that will have access to aggregate core comparison data, it is important that the data not be misused, or otherwise used, in any way that could lead to misunderstanding. If a system discloses or uses that information in any way other than in connection with its ORYX responsibilities (as described in the Performance Measurement System Agreement and Core Rider), it must:
- contact The Joint Commission to inform them of their intended use of such data (at oryxpms@jcaho.org);
- note that the information comes from The Joint Commission;
- note the quarters represented in the data being utilized;
- note the fact that The Joint Commission is not responsible for, nor has it reviewed the appropriateness of the system’s application of the information for any specific purpose other than ORYX; and
- note that The Joint Commission is in a continual process of updating the information and evaluating potential improvements in collecting the information.
Guidelines for core performance measurement systems for the use of core risk adjustment models
For those systems that will have access to core risk adjustment models, it is important that this information not be misused, or otherwise used, in any way that could lead to misunderstanding. If a system discloses or uses the models in any way other than in connection with its ORYX responsibilities (as described in the Performance Measurement System Agreement and Core Rider), it must explain:
- that the models come from The Joint Commission;
- any modifications the system has made to the models;
- the date of the system’s receipt of the models from The Joint Commission;
- the fact that The Joint Commission is not responsible for, nor has it reviewed the appropriateness of, the system’s application of the models for any specific purpose other than ORYX; and
- The Joint Commission will, as appropriate, evaluate and consider potential improvements in the core risk adjustment models.