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Thursday 3:42 CST, December 18, 2014


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Performance measurement

January 02, 2013

New accountability performance measures for 2012

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The Joint Commission has posted the designated accountability measures for 2012 on its website. The 2012 designated measures include four new measures and two measures that were removed from the pneumonia care (PN) set to create a new immunization (IMM) measure set. The measures are:

Hospital-Based Inpatient Psychiatric Services (HBIPS)
HBIPS-4a/HBIPS-5a      Patients discharged on multiple antipsychotic medications without appropriate
Note: HBIPS-4a and 5a will not be included in the Joint Commission’s calculation of composite rates for 2012. Beginning in 2013, only HBIPS-4a/HBIPS-5a (patients discharged on multiple antipsychotic medications without appropriate justification) will be reported. HBIPS-4a/HBIPS-5a is derived by subtracting HBIPS-5a (multiple antipsychotic medications at discharge with appropriate justification - overall rate) numerator cases (those cases with justification) from both the numerator and denominator of HBIPS-4a (multiple antipsychotic medications at discharge - overall rate).

Perinatal Care (PC)
PC-01                       Elective delivery
PC-03                       Antenatal steroids
PC-05 & PC-05a    Exclusive breast milk feeding & Exclusive breast milk feeding considering mother’s choice
Note: The exclusive breast milk measure (PC-05) is a stratified accountability measure. The stratum (PC-05a) has been created based on information gleaned from the test measure testing. Beginning in 2013, only strata measure PC-05a will be used in The Joint Commission’s accountability composite rate calculation.

Immunization (IMM)
IMM-1a                 Pneumococcal immunization
IMM-2                    Influenza vaccination

(Contact: Sharon Sprenger,



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