The Joint Commission Measure Set Definitions

The Joint Commission/Core Measures Initiative covers five focus areas. Below is a listing of each focus area and the individual measures for each.

Acute Myocardial Infarction (AMI)

AMI-1 Aspirin at Arrival – Acute myocardial infarction (AMI) patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival.

AMI-2  Aspirin Prescribed at Discharge - Acute myocardial infarction (AMI) patients without aspirin contraindications who are prescribed aspirin at hospital discharge.

AMI-3 ACEI or ARB for LVSD-Acute myocardial infarction (AMI) patients with left ventricular systolic dysfunction (LVSD) and without both angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) contraindications who are prescribed an ACEI or ARB at hospital discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular function (LVF) consistent with moderate or severe systolic dysfunction.

AMI-4 Adult Smoking Cessation Advice/Counseling- Acute myocardial infarction (AMI) patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay.  For purposes of this measure, a smoker is defined as someone who has smoked cigarettes anytime during the year prior to hospital arrival.

AMI-5 Beta Blocker Prescribed at Discharge-Acute myocardial infarction (AMI) patients without beta blocker contraindications who are prescribed a beta blocker at hospital discharge.

AMI-6 Beta Blocker at Arrival- Acute myocardial infarction (AMI) patients without beta blocker contraindications who received a beta blocker within 24 hours after hospital arrival.

AMI-7 Median Time to Thrombolysis- Median time from arrival to administration of a thrombolytic agent in patients with ST segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time.

AMI-7a Thrombolytic Agent Received Within 30 Minutes of Hospital Arrival - Acute myocardial infarction (AMI) patients receiving thrombolytic therapy during the hospital stay and having a time from hospital arrival to thrombolysis of 30 minutes or less.

AMI-8 Median Time to PTCA- Median time from arrival to percutaneous transluminal coronary angioplasty (PTCA) in patients with ST segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time.

AMI-8a PCI received within 90 minutes of hospital arrival - Acute myocardial infarction (AMI) patients receiving primary percutaneous coronary intervention (PCI) during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less.

AMI-9 JCAHO Only Inpatient mortality-AMI patients who expire during hospital stay.

Heart Failure 

HF-1 Discharge Instructions -Heart failure patients discharged home with written discharge instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following:

• activity level
• diet
• discharge medications
• follow-up appointment
• weight monitoring
• what to do if symptoms worsen.

HF-2 LVF Assessment-Heart failure patients with documentation in the hospital record that left ventricular function (LVF) was assessed before arrival, during hospitalization, or is planned for after discharge.

HF-3 ACEI or ARB for LVSD -Heart failure patients with left ventricular systolic dysfunction (LVSD) and without both angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) contraindications who are prescribed an ACEI or ARB at hospital discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular function (LVF) consistent with moderate or severe systolic dysfunction.

HF-4 Adult Smoking Cessation Advice/Counseling-Heart failure patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay.  For purposes of this measure, a smoker is defined as someone who has smoked cigarettes anytime during the year prior to hospital arrival.

Pneumonia 

PN-1 Oxygenation assessment-Pneumonia patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the hospital.

PN-2 Pneumococcal screening and/or vaccination-Pneumonia patients age 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated.

PN-3a Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival - Pneumonia patients transferred or admitted to the ICU within 24 hours of hospital arrival, who had blood cultures performed within 24 hours prior to or 24 hours after hospital arrival.

PN-3b Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital - Pneumonia patients whose initial emergency room blood culture specimen was collected prior to first hospital dose of antibiotics

PN-4 Adult smoking cessation advice/counseling-Pneumonia patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay.

PN-5 Antibiotic timing-The time, in minutes, from hospital arrival to administration of first antibiotic for inpatients with pneumonia.

PN-5a Initial antibiotic received within 8 hours of hospital arrival and

PN-5b Initial antibiotic received within 4 hours of hospital arrival - PN-5a: Pneumonia patients who receive their first dose of antibiotics within 8 hours after arrival at the hospital; PN 5b: Pneumonia patients who receive their first dose of antibiotics within 4 hours after arrival at the hospital.

(PN-6) Immunocompetent patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines

(PN-6a) Immunocompetent ICU patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines.

(PN-6b) Immunocompetent non-Intensive Care Unit (ICU) patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. -Immunocompetent patients for both ICU (PN-6a) and non-ICU (PN-6b) with pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines.

PN-7 Influenza vaccination-Pneumonia patients age 50 years and older, hospitalized during October, November, December, January, or February who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated.

Pregnancy and related conditions

PRC-1 VBAC -- Rate of patients who have had a vaginal delivery after a cesarean section."

PRC-2 Neonatal Mortality -- Live-born neonates who expire within 28
days after birth.

PRC-3 Third or Fourth Degree Laceration -- Patients who have vaginal deliveries with third or fourth degree laceration (tear).
 

Surgical Infection Prevention 

SCIP- Inf-1 Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision-Surgical patients who received prophylactic antibiotics within one hour prior to surgical incision. *Patients who received vancomycin or a fluoroquinolone for prophylactic antibiotics should have the antibiotics administered within two hours prior to surgical incision. Due to the longer infusion time required for vancomycin or a fluoroquinolone, it is acceptable to start these antibiotics within two hours prior to incision time.

SCIP- Inf-2 Prophylactic Antibiotic Selection for Surgical Patients- Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).

SCIP- Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time-Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.

Each indicator is stratified in the following manner:

SCIP- Inf-4 Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose - Cardiac surgery patients with controlled 6 A.M. serum glucose ( 200 mg/dL) on postoperative day one (POD 1) and postoperative day two (POD 2) with Surgery End Date being postoperative day zero (POD 0).

SCIP- Inf-6 Surgery Patients with Appropriate Hair Removal- Surgery patients with appropriate surgical site hair removal. No hair removal, or hair removal with clippers or depilatory is considered appropriate. Shaving is considered inappropriate.

SCIP- Inf-7 Colorectal Surgery Patients with Immediate Postoperative Normothermia- Colorectal surgery patients with immediate normothermia (96.8-100.4° F) within the first hour after leaving the operating room.
 

Effective with October 1, 2006 Discharges

Cardiac        

SCIP-Card-2  Surgery Patients on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period - Surgery patients on beta blocker therapy prior to admission who received a beta blocker during the perioperative period.  The perioperative period for the SCIP Cardiac measures is defined as 24 hours prior to surgical incision through discharge from post-anesthesia care/recovery area.

VTE   

SCIP-VTE-1   Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered - Surgery patients with recommended venous thromboembolism (VTE) prophylaxis ordered during the admission.

SCIP-VTE-2   Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery - Surgery patients who received appropriate venous thromboembolism (VTE) prophylaxis within 24 hours prior to Surgical Incision Time to 24 hours after Surgery End Time.