Download Joint Commission Accountability and Non

Compliance with Joint Commission
Accountability and Non-Accountability Measures
Tracking Worksheet
2014
Year Designated
2015
2016
Retired
Used to Calculate
Composite Rate for
2017 surveys
Reported to
The Joint
Commission
ACCOUNTABILITY MEASURES
Acute Myocardial Infarction (AMI)
AMI-1
Aspirin at arrival
AMI-2
Aspirin prescribed at
discharge
AMI-3
ACE inhibitor or ARB for
LVSD
AMI-5
Beta-blocker prescribed at
discharge
AMI-7a
Fibrinolytic therapy
received within 30 minutes
of hospital arrival
AMI-8a
Primary PCI received within
90 minutes of hospital
arrival
AMI-10
Statin prescribed at
discharge
Heart Failure (HF)
HF-3
ACE inhibitor or ARB for
LVSD
Pneumonia Care (PC)
PN-2
Pneumococcal vaccination
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
PN-3b
Blood cultures performed in
the emergency department
prior to initial antibiotic
received in hospital
© The Joint Commission. May be adapted for internal use.
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PN-6
Initial antibiotic selection
for community-acquired
pneumonia (CAP) in
immunocompetent patient
PN-7
Influenza vaccination
Surgical Care Improvement Project (SCIP)
SCIP-1a
Prophylactic antibiotic
received within 1 hour prior
to surgical incision
SCIP-2a
Appropriate prophylactic
antibiotic selection for
surgical patients
SCIP-3a
Prophylactic antibiotic
discontinued within 24
hours after surgery
SCIP-4
Cardiac surgery patients
with controlled 6 A.M.
postoperative blood glucose
SCIP-6
Surgery patients with
appropriate hair removal
SCIP-9
Urinary catheter removed
on postoperative day 1
(POD 1) or postoperative
day 2 (POD 2) with day of
surgery being day zero
SCIP-Card-2
Surgery patients on betablocker therapy prior to
arrival who received betablocker perioperatively
SCIP-VTE-1
Surgery patients with
recommended VTE
prophylaxis ordered
SCIP-VTE-2
Surgery patients who
received appropriate VTE
prophylaxis within 24 hours
prior to surgery and 24
hours after surgery
Children’s Asthma Care (CAC)
CAC-1a
Relievers for inpatient
asthma
CAC-2a
Systemic corticosteroids for
inpatient asthma
© The Joint Commission. May be adapted for internal use.
2
CAC-3
Home management plan of
care document given to
patient/caregiver
Hospital Inpatient Psychiatric Services (HBIPS)
HBIPS-2a
Hours of physical restraint
usei
HBIPS-3a
Hours of seclusion
HBIPS-4
Multiple antipsychotic
medications at discharge—
overall rate
HBIPS-5
Multiple antipsychotic
medications at discharge
with appropriate
justification—overall rate
HBIPS-6
Post discharge continuing
care plan—overall rate
HBIPS-7
Post discharge continuing
care plan transmitted—
overall rate
Venous Thromboembolism Care (VTE)
VTE-1
VTE prophylaxis
VTE-2
ICU VTE prophylaxis
VTE-3
VTE patients with
anticoagulation overlap
therapy
VTE-4
VTE patients receiving UFH
with dosages/platelet count
monitoring by protocol or
nomogram
VTE-5
VTE warfarin therapy
discharge instructions
Stroke Care (STK)
STK-1
Stroke patients with VTE
prophylaxis
STK-2
Discharged on
antithrombotic therapy
STK-3
Anticoagulation therapy for
atrial fibrillation/flutter
STK-4
Thrombolytic therapy
STK-5
Antithrombolytic therapy by
end of hospital day 2
STK-6
Discharged on statin
medication
© The Joint Commission. May be adapted for internal use.
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STK-8
Stroke education (discharge
instructions)
STK-10
Assessed for rehabilitation
NON-ACCOUNTABILITY MEASURES
Acute Myocardial Infarction (AMI)
AMI-4
Adult smoking cessation
advice/counseling
Heart Failure (HF)
HF-1
Discharge instructions
HF-2
Evaluation of LVS function
HF-4
Adult smoking cessation
advice/counseling
Pneumonia Care (PC)
PN-4
Adult smoking cessation
advice/counseling
PN-5c
Initial antibiotic received
within 6 hours of hospital
arrival
i
These process measures are reported as a ratio and will not be included in The Joint Commission’s
calculation of composite rates.
© The Joint Commission. May be adapted for internal use.
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