Modern-day hospital systems know how vital compliance and accreditation are, from securing federal reimbursements to ensuring patient safety and operational efficiency.
The Joint Commission (TJC), a significant accreditor for hospitals and other healthcare organizations in the U.S., has established benchmarks and standards since 1991. And in 2020, they announced substantial changes to how they measure hospital performance.
Understanding and complying with these updated guidelines can mean the difference between passing inspections and incurring violations (or losing federal reimbursements) for hospitals and healthcare systems.
To ensure your hospital maintains 100% compliance, learn how to adapt to the 2020 TJC changes and keep your accreditation standards.
The history of The Joint Commission healthcare performance measures
Hospitals have been held to a rigorous standard of care in the past few years, as evidenced by new core measures instituted by TJC.
Since 2003, TJC began to work with the Centers for Medicare and Medicaid Services (CMS) to align their standard measures as much as possible.
To achieve this, both CMS and TJC established a single set of measures called the "National Hospital Quality Measures Specifications Manual" that includes:
- Data dictionaries
- Algorithms
- Measure information forms
CMS and TJS hoped to minimize the efforts required while monitoring quality measurements across hospitals nationwide, in addition to improving healthcare delivery through historical data analysis.
2020 changes to The Joint Commission Reporting
The Joint Commission has devised new changes to help better improve hospital performance and improve the quality of healthcare.
TJC has updated three significant changes you need to be aware of on top of the annual requirements you must meet: Data file type, measure changes and submission methods.
Let's jump in!
Data file type
TJC now requires aggregate data submission rather than patient-level data submission. However, this will only be applicable for your hospital’s chart-abstracted measure submission.
This means that hospitals must submit their monthly performance every quarter and at an aggregate level instead of the patient level. By reporting the data monthly for every quarter, hospitals can demonstrate their performance in real-time.
TJC has also introduced a new level of data submission: The Daily Level. This is an aggregated version of what was once called "daily reports." With this reporting option, hospitals will be required to submit one daily report for each hospital unit every day they're open.
Measure changes
Initially, TJC aligned its measures with the CMS, but this has gradually changed over the years. With the new changes, there are ten active eCQMs and twenty-three active abstracted measures.
New measures have been developed within the ten active eCQMs, and those from previous years are being upgraded to a more rigorous measure of quality. Hospitals are also now required to submit discharge data used in determining compliance with TJC measures.
Some of the measures that have already been retired include the following:
- The measure for incidence of pressure ulcers in the hospital, which has been retired, is due to a change in regulations by CMS
- The safety and efficacy of antiseptic products used on patients was implemented in 2017 but has now been retired
Due to these changes, hospitals are required to update their policies and staff training programs.
Also, many hospitals have begun developing new systems for tracking data to report this information with TJC compliant measures accurately. Hospitals are also looking into ways to automate some processes, such as medication administration or EHR reporting.
Submission methods
TJC developed a Direct Data Submission (DDC) method for hospitals to submit their data to ensure a uniform data submission method.
The DDC submission method is designed to replace the submissions that are currently submitted through a secure login on the TJC website and paper-based submissions mailed or faxed to TJC's headquarters in Oak Brook, IL.
The new DDC system has three options:
- Uploading data directly from your electronic health records (EHR),
- Downloading preconfigured templates, and
- Submitting spreadsheets (.csv files) by email attachment
This can be done via uploading or downloading links provided on the Direct Data Submission site after logging into an account created during registration.
The Joint Commission's accountability measures
Accountability measures are quality metrics that, when hospitals improve on them, produce the most significant positive impact on patient outcomes.
TJC categorizes these process performance measurements into accountability and non-accountability measures. This approach places more emphasis on an organization's performance in meeting standards of accountability.
The approach typically includes four criteria designed to identify those quality indicators with proven power to affect patients' health care experience and outcome positively:
- Research — performing evidence-based care to improve health outcomes.
- Proximity — performing the care process is a connection to an improved outcome. Only a few clinical processes happen after completing one and before improvement occurs in any given case.
- Accuracy — You should be able to tell if you've delivered your service with enough effectiveness for improved outcomes.
- Adverse effects — Implemented correctly, this measure will have little or no chance of inducing unintended negative consequences.
Maintain 100% compliance across hospitals
The 2020 Joint Commission measure change for hospitals is a complicated subject. The goal of this article was to provide you with the information in an easy-to-understand format and break down what each of these changes means for your hospital.
This comprehensive guide will prove helpful to you as you work towards meeting the requirements set forth by TJC and improving the safety, quality, efficiency, and cost-effectiveness of care at your facility.
To learn more about TJC changes and CMS, FSI's healthcare CMMS software, get in touch.