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Facts about accountability measures

September 4, 2014

The Joint Commission categorizes its process performance measures into accountability and non-accountability measures. This approach places more emphasis on an organization’s performance on accountability measures – quality measures that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement:

Research: Strong scientific evidence demonstrates that performing the evidence-based care process improves health outcomes (either directly or by reducing risk of adverse outcomes).

Proximity: Performing the care process is closely connected to the patient outcome; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs.

Accuracy: The measure accurately assesses whether or not the care process has actually been provided. That is, the measure should be capable of indicating whether the process has been delivered with sufficient effectiveness to make improved outcomes likely.

Adverse Effects: Implementing the measure has little or no chance of inducing unintended adverse consequences.

Measures that meet all four criteria should be used for purposes of accountability (e.g., for accreditation, public reporting, or pay-for-performance). Those measures that have not been designated as accountability measures may be useful for quality improvement, exploration and learning within individual health care organizations, and are good advice in terms of appropriate patient care. Going forward, The Joint Commission will have a primary focus on adopting accountability measures for its ORYX program. The Joint Commission will continue to re-examine all process (i.e., proportion and ratio) measures categorized as accountability measures to ensure they continue to meet the accountability criteria.

Integrating accountability measures into accreditation
The Joint Commission has integrated accountability measures into the accreditation process in the following ways:

  • Effective January 1, 2012, Joint Commission accredited hospitals (not critical access hospitals) were required to meet a new performance improvement requirement (standard PI.02.01.03 element of performance 1) that established an 85 percent composite compliance target rate for performance on ORYX accountability measures. Compliance with the EP, which has been identified as a direct impact requirement, is based on performance on a single composite measure rate for all reported accountability measures. The target rate is based on research of past ORYX performance data that shows increasing levels of compliance with accountability measures. An organization that is not in compliance with the target rate at the time of the triennial survey would receive a Requirement for Improvement (RFI) in its accreditation report.

  • Launched in September 2011, The Joint Commission’s Top Performer on Key Quality Measures® program recognizes accredited hospitals that attain excellence on accountability measure performance.

  • The Joint Commission provides a Core Measure Solution Exchange®, which promotes the sharing of success stories among hospitals

For more about accountability measures
Read “Accountability Measures: Using Measurement to Promote Quality Improvement,” in the June 23, 2010 online issue of the New England Journal of Medicine, for which Mark R. Chassin, M.D., FACP, M.P.P, M.P.H., president and chief executive officer of The Joint Commission, was the lead author.



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