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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. 1 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. 3 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. 4