Performance Measurement and Improvement for Disease-Specific Care Certification Programs | Joint Commission
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Performance Measurement and Improvement for Disease-Specific Care Certification Programs

May 15, 2014

The standards for Performance Measurement and Improvement focus on four key areas:

  • Creating an organized comprehensive approach to performance improvement
  • Utilizing comparative data to evaluate program processes and patient outcomes
  • Evaluating participants’ perception of care quality, and
  • Maintaining data quality and integrity

The performance measurement requirements for Disease-Specific Care (DSC) Certification programs comprise two stages:

  • Stage I – Non-Standardized Measures:  DSC certification programs and services are required to collect and analyze data on 4 or more performance measures.  At least 2 of the 4 should be clinical measures related to or identified in clinical practice guidelines for that program or service.  Measures selected by the program or service should be evidence-based, relevant, valid and reliable.  The Joint Commission is not prescriptive during Stage I regarding the specific measures that are implemented; the emphasis is on the use of performance measures for improving care.

  • Stage II – Standardized Measures:  Standardized performance measures have precisely defined specifications, standardized data collection protocols, meet established evaluation criteria and can be uniformly adopted for use.  Standardized sets of measures are identified and specified by The Joint Commission and external performance measurement experts. When available, standardized measures replace non-standardized measures and are uniformly adopted by all certified programs, as well as programs seeking initial certification.  Standardized performance measures are currently available for the following advanced certification programs : Advanced Certification  for Heart Failure, Comprehensive Stroke Certification, and Primary Stroke Center Certification.  

Performance Measurement Requirements for DSC Certification

The standards require the DSC program to demonstrate that it:

  • Routinely applies the cycle for performance improvement to identify and address improvement opportunities
  • Implements a plan for improvement and graphically depicts measurement results over time to demonstrate improvement in the measured areas
  • Reports data to The Joint Commission
  • Reviews the effectiveness of the interventions implemented in response to improvement opportunities identified by the measurement activity

Specific performance measurement requirements for all certified programs include:

  • Collection of monthly data points for both standardized and non-standardized measures
  • Prior to initial certification, collection of a minimum of  4 months of performance measure data for each standardized and/or non-standardized measure submitted at the time of application
  • Utilization of the Certification Measure Information Process (CMIP) available through The Joint Commission Connect™ to electronically report data to The Joint Commission
    • Submission of non-standardized measure data required prior to the  time of the intra-cycle review and recertification
  • Core measure data submission for certification purposes using CMIP or through a core measure vendor selected by the organization (NOTE: The same vendor must be used if the core measure set is used by the organization to meet both certification and hospital accreditation performance measure requirements).
    • Quarterly submission of monthly data points required for standardized measure data
  • Completion of Performance Measure Data Report questions in CMIP for each measure collected prior to intra-cycle review and recertification 

Performance Measurement for Disease-Specific Care Certification

Advanced Certification for Heart Failure

Measure specifications for the six mandatory inpatient advanced certification for heart failure (ACHF) measures are detailed in the ACHF Performance Measurement Implementation Guide. . A separate performance measurement implementation guide for the ACHF Outpatient measure set is also available via this page.

Heart Failure
The heart failure (HF) measures can be found in the Specification Manual for National Hospital Inpatient Quality Measures.

Comprehensive Stroke
Measure specifications for the eight new comprehensive stroke (CSTK) measures are detailed in the CSTK Performance Measurement Implementation Guide.

The stroke (STK) measures can be found in the Specification Manual for National Hospital Inpatient Quality Measures.

Stroke Performance Measure Advisory Panel 
For additional information about Performance Measurement for Disease-Specific Care Certification, please submit your question online.