Certification Performance Measurement Reporting

The Joint Commission integrates the receipt of performance measurement data into the certification process. The Certification Measure Information Process (CMIP) tool is applicable to all health care organizations that are currently certified or are seeking certification for the first time. The CMIP tool has an electronic form that hospitals use to submit certification performance measurement data and performance improvement information to The Joint Commission.

For any questions related to the Certification process, please contact your Account Executive directly.

Performance Measurement Requirements for Certification

Performance Measurement requirements for all certified programs include the following:

  • Collection of monthly aggregate data on non-standardized or, where applicable and available, standardized performance measures
  • For the initial certification on-site review, collect a minimum of four months of performance measure data for each standardized and/or non-standardized measure and complete the Performance Improvement Plan (see “Performance Improvement Plan”). Aggregate data collected should be reported to The Joint Commission prior to the on-site review

For certified programs reporting on aggregate non-standardized measures:

  • At least annual reporting of non-standardized measure data to The Joint Commission via the Certification Measure Information Process (CMIP) tool.
  • Aggregate monthly data values for each measure reported prior to the intracycle event and recertification review

For advanced certification programs required to report on standardized measures:

  • Reporting of standardized measures to The Joint Commission via Certification Measure Information Process (CMIP) tool
  • Aggregate monthly data values reported on a quarterly basis for each measure
  • Data to be received by The Joint Commission no later than four months following the end of the calendar quarter

For information on the applicable standardized measures for respective advanced certification programs, refer to the individual measure topic pages under the “Measures” section of the website and expand the section “Measures by Certification Program”.