ncqa level 3 pcmh recognition requirements compared to … · ncqa level 3 pcmh recognition...

NCQA Level 3 PCMH Recognition Requirements Compared to 2013 Joint Commission Standards and EPs

This tool, prepared by The Joint Commission, compares the National Committee for Quality Assurance (NCQA) general standard areas for its 2011 version of the Patient-Centered Medical Home to the specific Joint Commission requirements for its Primary Care Medical Home. While there are differences between The Joint Commission’s evaluation and scoring process (see table below), this analysis demonstrates that The Joint Commission’s Primary Care Medical Home option requirements are comparable to NCQA’s Patient-Centered Medical Home Level 3 requirements.

FEATURE THE JOINT COMMISSION NCQA

Name Primary Care Medical Home Patient-Centered Medical Home

Award Label Certification

Recognition

Accreditation of organization also required? YES NO

Levels of Achievement? NO YES: Levels 1, 2, 3

Need to submit documentation? NO YES

On-site survey process for all organizations to evaluate compliance?

YES NO

(Conducted through on-line submission of documentation)

On-site consultation regarding approaches to standards compliance?

YES NO

Copy of preliminary report available on site? YES NO

Scope of Evaluation Entire organization Delivery site specific

Length of award 3 years 3 year

2011 NCQA Level 3 PCMH Recognition Requirements Compared to 2013 Joint Commission Hospital Standards and EPs

Description of NCQA StandardsJoint Commission

Equivalent NumberJoint Commission Standards and Elements of Performance

I. Access and Continuity

*A.

In this section, the NCQA standards address offering patients appointments on the day they call and providing health care advice by electronic methods and on the telephone when the office is open. NCQA requires that the advice provided is entered in the patient's medical record. It also requires organizations to have written procedures for these activities and measure whether it is following its procedures.

*denotes a requirement that NCQA says must be met

LD.01.03.01 The governing body is ultimately accountable for the safety and quality of care,

treatment, and services.

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home evaluates the effectiveness of how the primary care clinician and the interdisciplinary team partner with the patient to support continuity of care and comprehensive, coordinated care.

EP 20

PC.02.04.01 For hospitals that elect The Joint Commission Primary Care Medical Home option: The

patient has access to the primary care medical home 24 hours a day, 7 days a week.

Note: Access may be provided through a number of methods, including telephone, e-

mail, flexible hours, websites, and portals.

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home provides patients with access to the following 24 hours a day, 7 days a week: - Appointment availability/scheduling - Requests for prescription renewal - Test results - Clinical advice for urgent health needs

EP 1

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home offers flexible scheduling to accommodate patient care needs. Note: This may include open scheduling, same-day appointments, group visits, expanded hours, and arrangements with other organizations.

EP 2

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home has a process to address patient urgent care needs 24 hours a day, 7 days a week.

EP 3

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This crosswalk demonstrates that The Joint Commission PCMH standards are comparable to NCQA's Level 3 PCMH Recognition requirements




primary care medical home is accountable for providing patient care. (Refer to

Standard PC.02.04.05)

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home uses health information technology to do the following: - Support the continuity of care, and the provision of comprehensive and coordinated care, treatment, or services - Document and track care, treatment, or services - Support disease management, including providing patient education - Support preventive care, treatment, or services - Create reports for internal use and external reporting - Facilitate electronic exchange of information among providers - Support performance improvement

EP 5

PI.01.01.01 The hospital collects data to monitor its performance.

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home collects data on the following: Patient access to care within time frames established by the hospital.

EP 41

PI.03.01.01 The hospital improves performance on an ongoing basis.

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home uses the data it collects on the patient’s perception of the safety and quality of care, treatment, or services to improve its performance. This data includes the following: - Patient experience and satisfaction related to access to care, treatment, or services and communication - Patient perception of the comprehensiveness of care, treatment, or services - Patient perception of the coordination of care, treatment, or services - Patient perception of the continuity of care, treatment, or services

EP 11

RC.01.01.01 The hospital maintains complete and accurate medical records for each individual

patient.

The hospital defines the components of a complete medical record.EP 1

The medical record contains the information needed to support the patient’s diagnosis and condition.EP 5

The medical record contains the information needed to justify the patient’s care, treatment, and services.EP 6

The hospital uses standardized formats to document the care, treatment, and services it provides to patients.

EP 9

B.

In this section, the NCQA standards address offering patients appointments (both regular and urgent) when the organization is closed and providing health care advice by electronic methods and on the telephone when the office is closed. These are done within reasonable timeframes. NCQA requires that the care and advice provided when the organization is closed is entered in the patient’s medical record. It also requires organizations to have written procedures for these activities and measure whether it is following its

IM.02.02.03 The hospital retrieves, disseminates, and transmits health information in useful

formats.

The hospital's storage and retrieval systems make health information accessible when needed for patient care, treatment, and services. (See also IC.01.02.01, EP 1)Note: For hospitals that use Joint Commission accreditation for deemed status purposes: The medical records system allows for timely retrieval of patient information by diagnosis and procedure.

EP 2


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procedures. LD.01.03.01 The governing body is ultimately accountable for the safety and quality of care,



EP 20






EP 1

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home offers flexible scheduling to accommodate patient care needs. Note: This may include open scheduling, same-day appointments, group visits, expanded hours, and arrangements with other organizations.

EP 2

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home has a process to address patient urgent care needs 24 hours a day, 7 days a week.

EP 3




For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home manages transitions in care and provides or facilitates patient access to care, treatment, or services including the following: - Acute care - Management of chronic care - Preventive services that are age- and gender-specific - Behavioral health needs - Oral health care - Urgent and emergent care - Substance abuse treatment Note: Some of these services may be obtained through the use of community resources as available, or in collaboration with other organizations.

EP 1


EP 5


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For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home collects data on the following: Patient access to care within time frames established by the hospital.

EP 41

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home collects data on the following: - Patient experience and satisfaction related to access to care, treatment, or services, and communication - Patient perception of the comprehensiveness of care, treatment, or services - Patient perception of the coordination of care, treatment, or services - Patient perception of the continuity of care, treatment, or services(Refer to PI.01.01.01, EP 16)

EP 42



EP 11


patient.




The medical record contains information that documents the course and result of the patient's care, treatment, and services.

EP 7

The medical record contains information about the patient’s care, treatment, or services that promotes continuity of care among providers. Note: For hospitals that elect The Joint Commission Primary Care Medical Home option: This requirement refers to care provided by both internal and external providers.

EP 8


EP 9

RC.02.01.07 The medical record contains a summary list for each patient who receives continuing

ambulatory care services.

A summary list is initiated for the patient by his or her third visit.EP 1


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The patient’s summary list contains the following information:- Any significant medical diagnoses and conditions- Any significant operative and invasive procedures- Any adverse or allergic drug reactions- Any current medications, over-the-counter medications, and herbal preparations

EP 2

The patient’s summary list is updated whenever there is a change in diagnoses, medications, or allergies to medications, and whenever a procedure is performed.

EP 3

The summary list is readily available to practitioners who need access to the information of patients who receive continuing ambulatory care services in order to provide care, treatment, and services.

EP 4

C.

In this section, the NCQA standards address allowing patients to contact the organization and receive responses electronically, and to request appointments, prescriptions, referrals, and test results electronically. NCQA also sets the following targets for providing patients with health care information electronically: more than half of the patients who request health information receive it within three business days; more than half of the patients having office visits are able to receive clinical summaries within three business day; after health information is available to the organization, access is provided to at least ten percent of patients within four business days.






EP 1





EP 5

RI.01.01.01 The hospital respects, protects, and promotes patient rights.

The hospital respects the patient’s right to and need for effective communication. (See also RI.01.01.03, EP 1)

EP 5

D.

In this section, the NCQA standards address patient selection of a primary care clinician, recording the patient’s choice of a primary care clinician, and determining how many of the patient’s visits are with the selected primary care clinician.

PC.02.01.01 The hospital provides care, treatment, and services for each patient.

For hospitals that elect The Joint Commission Primary Care Medical Home option: Each patient has a designated primary care clinician.

EP 16

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home allows the patient to select his or her primary care clinician.

EP 17


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RI.01.04.03 For hospitals that elect The Joint Commission Primary Care Medical Home option: The

primary care medical home provides patients with information about its functions and

services.

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home provides information to the patient about: How it functions, including the following: - Processes supporting patient selection of a primary care clinician - Involving the patient in his or her treatment plan - Obtaining and tracking referrals - Coordinating care - Collaborating with patient-selected clinicians who provide specialty care or second opinions Note: Supporting patients in selecting a primary care clinician may include providing patients with information regarding the clinician’s credentials, area(s) of specialty, interests, languages spoken, and gender.

EP 3

E.

In this section, the NCQA standards address providing the patient with information on the functioning of the medical home. It also addresses coordinating care that is provided in different locations, giving the patient information on how to obtain care and advice when the organization is open or closed, providing the patient with care that is based on evidence, and supporting the patient in managing his or her care. NCQA expects that the patient provides the organization with complete information about his or her health care history and information about care provided by other organizations.



services.

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home provides information to the patient about: Its mission, vision, and goals. (Refer to LD.02.01.01, EP 3) Note: This may include how it provides for patient-centered and team-based comprehensive care, a systems-based approach to quality and safety, and enhanced patient access.

EP 1

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home provides information to the patient about: The scope of care and types of services it provides. (Refer to PC.01.01.01, EP 7; LD.01.03.01, EP 3)

EP 2


EP 3

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home provides information to the patient about: How to access the organization for care or information.

EP 4

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home provides information to the patient about: Patient responsibilities, including providing health history and current medications, and participating in self-management activities. (Refer to RI.02.01.01, EP 2)

EP 5

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home provides information to the patient about: The patient’s right to obtain care from other clinicians within the primary care medical home, to seek a second opinion, and to seek specialty care. (Refer to PC.02.03.01, EP 4; RI.01.01.03, EPs 1 and 3)

EP 6


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RI.02.01.01 The hospital informs the patient about his or her responsibilities related to his or her

care, treatment, and services.

The hospital informs the patient about his or her responsibilities in accordance with its policy. Note: Information about patient responsibilities can be shared verbally, in writing, or both.

EP 2

F.

In this section, the NCQA standards address identifying the primary languages of patients, providing interpretation services and written materials in accordance with patient language needs, and gathering information on the racial and ethnic characteristics of patients.

PC.02.01.21 The hospital effectively communicates with patients when providing care, treatment,

and services.

The hospital identifies the patient's oral and written communication needs, including the patient's preferred language for discussing health care. (See also RC.02.01.01, EP 1)Note: Examples of communication needs include the need for personal devices such as hearing aids or glasses, language interpreters, communication boards, and translated or plain language materials.

EP 1

The hospital communicates with the patient during the provision of care, treatment, and services in a manner that meets the patient's oral and written communication needs. (See also RI.01.01.03, EPs 1-3)

EP 2




For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home provides population-based care.

EP 4


EP 5

RC.02.01.01 The medical record contains information that reflects the patient's care, treatment, and

services.

The medical record contains the patient’s race and ethnicity.EP 28

RI.01.01.01 The hospital respects, protects, and promotes patient rights.

The hospital respects the patient’s right to and need for effective communication. (See also RI.01.01.03, EP 1)

EP 5

The hospital respects the patient’s cultural and personal values, beliefs, and preferences.EP 6

RI.01.01.03 The hospital respects the patient's right to receive information in a manner he or she

understands.

The hospital provides information in a manner tailored to the patient's age, language, and ability to understand. (See also PC.02.01.21, EP 2; PC.04.01.05, EP 8; RI.01.01.01, EPs 2 and 5)

EP 1


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The hospital provides language interpreting and translation services. (See also HR.01.02.01, EP 1; PC.02.01.21, EP 2; RI.01.01.01, EPs 2 and 5)Note: Language interpreting options may include hospital-employed language interpreters, contract interpreting services, or trained bilingual staff. These options may be provided in person or via telephone or video. The hospital determines which translated documents and languages are needed based on its patient population.

EP 2

G.

In this section, the NCQA standards address defining the roles of members of the care team, holding regular team meetings, and using standing orders. NCQA requires team members to participate actively in performance improvement initiatives.

It also requires team member training on coordinating care, helping patients to manage their care and make necessary changes in their actions that affect their health, how to address population management, and how to communicate.

HR.01.02.01 The hospital defines staff qualifications.

The hospital defines staff qualifications specific to their job responsibilities. (See also IC.01.01.01, EP 3 and RI.01.01.03, EP 2) Note 1: Qualifications for infection control may be met through ongoing education, training, experience, and/or certification (such as that offered by the Certification Board for Infection Control). Note 2: Qualifications for laboratory personnel are described in the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88), under Subpart M: “Personnel for Nonwaived Testing” §493.1351-§493.1495. A complete description of the requirement is located at http://wwwn.cdc.gov/clia/regs/toc.aspx.Note 3: For hospitals that use Joint Commission accreditation for deemed status purposes: Qualified physical therapists, physical therapist assistants, occupational therapists, occupational therapy assistants, speech-language pathologists, or audiologists (as defined in 42 CFR 484.4) provide physical therapy, occupational therapy, speech-language pathology, or audiology services, if these services are provided by the hospital.Note 4: Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training, and experience. The use of qualified interpreters and translators is supported by the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973, and Title VI of the Civil Rights Act of 1964.

EP 1

HR.01.02.07 The hospital determines how staff function within the organization.

All staff who provide patient care, treatment, and services possess a current license, certification, or registration, in accordance with law and regulation.

EP 1

Staff who provide patient care, treatment, and services practice within the scope of their license, certification, or registration and as required by law and regulation. (See also HR.01.02.05, EPs 1 and 2)

EP 2

HR.01.04.01 The hospital provides orientation to staff.

The hospital orients staff on the following: Relevant hospital-wide and unit-specific policies and procedures. Completion of this orientation is documented.

EP 3

The hospital orients staff on the following: Their specific job duties, including those related to infection prevention and control and assessing and managing pain. Completion of this orientation is documented. (See also IC.01.05.01, EP 6; IC.02.01.01, EP 7; IC.02.04.01, EP 2; RI.01.01.01, EP 8)

EP 4

The hospital orients staff on the following: Sensitivity to cultural diversity based on their job duties and responsibilities. Completion of this orientation is documented.

EP 5

The hospital orients staff on the following: Patient rights, including ethical aspects of care, treatment, and services and the process used to address ethical issues based on their job duties and responsibilities. Completion of this orientation is documented.

EP 6

HR.01.05.03 Staff participate in ongoing education and training.

Staff participate in ongoing education and training to maintain or increase their competency. Staff participation is documented.

EP 1


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Staff participate in ongoing education and training whenever staff responsibilities change. Staff participation is documented.

EP 4

Staff participate in education and training that is specific to the needs of the patient population served by the hospital. Staff participation is documented. (See also PC.01.02.09, EP 3)

EP 5

Staff participate in education and training that incorporates the skills of team communication, collaboration, and coordination of care. Staff participation is documented.

EP 6

LD.03.04.01 The hospital communicates information related to safety and quality to those who need

it, including staff, licensed independent practitioners, patients, families, and external

interested parties.

Communication processes foster the safety of the patient and the quality of care.EP 1

Communication is designed to meet the needs of internal and external users.EP 3

Leaders provide the resources required for communication, based on the needs of patients, the community, physicians, staff, and management.

EP 4

Communication supports safety and quality throughout the hospital. (See also LD.04.04.05, EPs 6 and 12)

EP 5

When changes in the environment occur, the hospital communicates those changes effectively.EP 6

Leaders evaluate the effectiveness of communication methods.EP 7

MM.04.01.01 Medication orders are clear and accurate.

The hospital has a written policy that identifies the specific types of medication orders that it deems acceptable for use. Note: There are several different types of medication orders. Medication orders commonly used include the following:- As needed (PRN) orders: orders acted on based on the occurrence of a specific indication or symptom- Standing orders: A pre-written medication order and specific instructions from the licensed independent practitioner to administer a medication to a person in clearly defined circumstances- Automatic stop orders: Orders that include a date or time to discontinue a medication- Titrating orders: Orders in which the dose is either progressively increased or decreased in response to the patient’s status- Taper orders: Orders in which the dose is decreased by a particular amount with each dosing interval- Range orders: Orders in which the dose or dosing interval varies over a prescribed range, depending on the situation or patient’s status- Orders for compounded drugs or drug mixtures not commercially available- Orders for medication-related devices (for example, nebulizers, catheters)- Orders for investigational medications- Orders for herbal products- Orders for medications at discharge or transfer

EP 1

The hospital implements its policies for medication orders. EP 13


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For hospitals that use Joint Commission accreditation for deemed status purposes: Processes for the use of pre-printed and electronic standing orders, order sets, and protocols for medication orders include the following:- Review and approval of standing orders and protocols by the medical staff and the hospital’s nursing and pharmacy leadership- Evaluation of established standing orders and protocols for consistency with nationally recognized and evidence-based guidelines- Regular review of such standing orders and protocols by the medical staff and the hospital’s nursing and pharmacy leadership to determine the continuing usefulness and safety of the standing orders and protocols- Dating, timing, and authenticating of standing orders and protocols by the ordering practitioner or another practitioner responsible for the patient’s care in accordance with professional standards of practice; law and regulation; hospital policies; and medical staff bylaws, rules, and regulations.

EP 15

MS.03.01.03 The management and coordination of each patient’s care, treatment, and services is

the responsibility of a practitioner with appropriate privileges.

There is coordination of the care, treatment, and services among the practitioners involved in a patient’s care, treatment, and services.

EP 6

MS.12.01.01 All licensed independent practitioners and other practitioners privileged through the

medical staff process participate in continuing education.

Hospital-sponsored educational activities are prioritized by the organized medical staff.EP 1

These activities relate, at least in part, to the type and nature of care, treatment, and services offered by the hospital.

EP 2

Education is based on the findings of performance improvement activities.EP 3

Each individual’s participation in continuing education is documented.EP 4

PC.02.01.05 The hospital provides interdisciplinary, collaborative care, treatment, and services.

Care, treatment, and services are provided to the patient in an interdisciplinary, collaborative manner.EP 1

PC.02.02.01 The hospital coordinates the patient’s care, treatment, and services based on the

patient’s needs.

The hospital has a process to receive or share patient information when the patient is referred to other internal or external providers of care, treatment, and services. (See also PC.04.02.01, EP 1)

EP 1

The hospital's process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient information.Note: Such information may include the patient’s condition, care, treatment, medications, services, and any recent or anticipated changes to any of these.

EP 2

The hospital coordinates the patient’s care, treatment, and services. Note: Coordination involves resolving scheduling conflicts and duplication of care, treatment, and services.

EP 3

When the hospital uses external resources to meet the patient’s needs, it coordinates the patient’s care, treatment, and services.

EP 10


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PC.02.03.01 The hospital provides patient education and training based on each patient’s needs

and abilities.

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care clinician and the interdisciplinary team educate the patient on self-management tools and techniques based on the patient’s individual needs.

EP 28





EP 4


primary care clinician and the interdisciplinary team work in partnership with the

patient to support the continuity of care and the provision of comprehensive and

coordinated care, treatment, or services.

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home identifies the composition of the interdisciplinary team, based on individual patient needs.

EP 1

For hospitals that elect The Joint Commission Primary Care Medical Home option: The members of the interdisciplinary team provide comprehensive and coordinated care, treatment, or services and maintain the continuity of care. Note: The provision of care may include making internal and external referrals.

EP 2

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care clinician and the interdisciplinary team provide care for a designated group of patients.

EP 4

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care clinician is responsible for making certain that the interdisciplinary team provides comprehensive and coordinated care, treatment, or services and maintains the continuity of care as described in EPs 6 through 13. Note: Coordination of care may include making internal and external referrals, developing and evaluating treatment plans, and resolving conflicts in the provision of care.

EP 5

For hospitals that elect The Joint Commission Primary Care Medical Home option: When a patient is referred internally or externally, the interdisciplinary team reviews and tracks the care provided to the patient.

EP 6

For hospitals that elect The Joint Commission Primary Care Medical Home option: The interdisciplinary team participates in the development of the patient’s treatment plan.

EP 8

For hospitals that elect The Joint Commission Primary Care Medical Home option: The interdisciplinary team works in partnership with the patient to achieve planned outcomes.

EP 9

For hospitals that elect The Joint Commission Primary Care Medical Home option: The interdisciplinary team monitors the patient’s progress toward achieving treatment goals.

EP 10

For hospitals that elect The Joint Commission Primary Care Medical Home option: The interdisciplinary team actively participates in performance improvement activities.

EP 13


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II. Patient Populations

A.

In this section, the NCQA standards address using an electronic health record for more than half of the organization’s patients that includes information on the patient’s date of birth, gender, race and ethnicity, language, legal guardians, primary care givers, and the existence of advance directives for adults. NCQA also requires the organization to record information about appointments, methods of contact, such as telephone numbers and email addresses, and insurance coverage. NCQA states that this information can be identified in the electronic record through a search function.





EP 5


patient.


The medical record contains information unique to the patient, which is used for patient identification.EP 4

All entries in the medical record are dated.EP 11


services.

The medical record contains the following demographic information:- The patient's name, address, and date of birth and the name of any legally authorized representative- The patient’s sex- The legal status of any patient receiving behavioral health care services- The patient's communication needs, including preferred language for discussing health care (See also PC.02.01.21, EP 1)Note: If the patient is a minor, is incapacitated, or has a designated advocate, the communication needs of the parent or legal guardian, surrogate decision-maker, or legally authorized representative is documented in the medical record.

EP 1

As needed to provide care, treatment, and services, the medical record contains the following additional information: - Any advance directives (See also RI.01.05.01, EP 11)- Any informed consent, when required by hospital policy (See also RI.01.03.01, EP 13) Note: The properly executed informed consent is placed in the patient’s medical record prior to surgery, except in emergencies. A properly executed informed consent contains documentation of a patient’s mutual understanding of and agreement for care, treatment, and services through written signature; electronic signature; or, when a patient is unable to provide a signature, documentation of the verbal agreement by the patient or surrogate decision-maker.- Any records of communication with the patient, such as telephone calls or e-mail- Any patient-generated information

EP 4



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B.

In this section, the NCQA standards set targets for entering clinical data in the electronic record. Those targets are: a current summary list and a list of allergies for more than 80% of the patients; current prescription medications for more than 80% of the patients; dated blood pressure rates for more than half of the patients; height and weight for more than half of the patients; BMI for more than half of the patients who are adults; BMI percentile for more than half of the patients between 2 and 20 years old; height (or body length), weight, and head circumference for more than half the patients who are less than two years old; use of tobacco for more than half of the patients who are age 13 or older. NCQA states that this information can be identified in the electronic record through a search function, and the care provided to pediatric patients can be tracked over time.

NPSG.03.06.01 Maintain and communicate accurate patient medication information.

Obtain information on the medications the patient is currently taking when he or she is admitted to the hospital or is seen in an outpatient setting. This information is documented in a list or other format that is useful to those who manage medications. Note 1: Current medications include those taken at scheduled times and those taken on an as-needed basis. See the Glossary for a definition of medications. Note 2: It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information from the patient and/or other sources will be considered as meeting the intent of the EP.

EP 1

Define the types of medication information to be collected in non–24-hour settings and different patient circumstances. Note 1: Examples of non–24-hour settings include the emergency department, primary care, outpatient radiology, ambulatory surgery, and diagnostic settings. Note 2: Examples of medication information that may be collected include name, dose, route, frequency, and purpose.

EP 2

Compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital in order to identify and resolve discrepancies. Note: Discrepancies include omissions, duplications, contraindications, unclear information, and changes. A qualified individual, identified by the hospital, does the comparison. (See also HR.01.06.01, EP 1)

EP 3

PC.01.03.01 The hospital plans the patient’s care.

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home uses clinical decision support tools to guide decision making. (Refer to LD.04.04.07, EPs 1-5)

EP 45





EP 5





For hospitals that elect The Joint Commission Primary Care Medical Home option: The interdisciplinary team assesses patients for health risk behaviors.

EP 12


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patient.


The medical record contains information unique to the patient, which is used for patient identification.EP 4




EP 7


EP 9

The hospital assembles or makes available in a summary in the medical record all information required to provide patient care, treatment, and services. (See also MM.01.01.01, EP 1)

EP 13


services.

The medical record contains the following clinical information:- The reason(s) for admission for care, treatment, and services- The patient’s initial diagnosis, diagnostic impression(s), or condition(s)- Any findings of assessments and reassessments (See also PC.01.02.01, EPs 1 and 4; PC.03.01.03, EPs 1 and 8)- Any allergies to food- Any allergies to medications- Any conclusions or impressions drawn from the patient’s medical history and physical examination- Any diagnoses or conditions established during the patient’s course of care, treatment, and services- Any consultation reports- Any observations relevant to care, treatment, and services- The patient’s response to care, treatment, and services- Any emergency care, treatment, and services provided to the patient before his or her arrival- Any progress notes- All orders- Any medications ordered or prescribed- Any medications administered, including the strength, dose, and route- Any access site for medication, administration devices used, and rate of administration- Any adverse drug reactions- Treatment goals, plan of care, and revisions to the plan of care (See also PC.01.03.01, EPs 1 and 23)- Results of diagnostic and therapeutic tests and procedures- Any medications dispensed or prescribed on discharge- Discharge diagnosis- Discharge plan and discharge planning evaluation(See also PC.01.02.03, EPs 6-8)

EP 2





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EP 2


EP 3


EP 4

C.

In this section, the NCQA standards address assessing each patient’s health status, including potential health risks and information needs. NCQA requires that the following information is documented: depression screening for adults and children over 13 using standardized tools; patient-specific communication issues; immunizations and screenings recommended for various ages and genders; the patient’s and his or her family’s health history; plans that address end-of-life care for adult patients only; family or social and cultural preferences; health risk behaviors; history of substance abuse by the patient or family; developmental screening for children using standardized tools. NCQA states that this information can be identified in the electronic record through a search function.

PC.01.02.01 The hospital assesses and reassesses its patients.

The hospital defines, in writing, the scope and content of screening, assessment, and reassessment information it collects. (See also RC.02.01.01, EP 2)Note 1: In defining the scope and content of the information it collects, the organization may want to consider information that it can obtain, with the patient’s consent, from the patient’s family and the patient’s other care providers, as well as information conveyed on any medical jewelry.Note 2: Assessment and reassessment information includes the patient’s perception of the effectiveness of, and any side effects related to, his or her medication(s).

EP 1

The hospital defines, in writing, criteria that identify when additional, specialized, or more in-depth assessments are performed. (See also PC.01.02.07, EP 1; PC.01.02.03 EPs 7 and 8) Note: Examples of criteria could include those that identify when a nutritional, functional, or pain assessment should be performed for patients who are at risk.

EP 2

The hospital has defined criteria that identify when nutritional plans are developed. (See also PC.01.02.03, EP 7)

EP 3

Based on the patient's condition, information gathered in the initial assessment includes the following:- Physical, psychological, and social assessment- Nutrition and hydration status- Functional status- For patients who are receiving end-of-life care, the social, spiritual, and cultural variables that influence the patient’s and family members’ perception of grief(See also RC.02.01.01, EP 2)

EP 4

During patient assessments and reassessments, the hospital gathers the data and information it requires. (See also PC.01.01.01, EP 24)

EP 23

PC.01.02.09 The hospital assesses the patient who may be a victim of possible abuse and neglect.

The hospital has written criteria to identify those patients who may be victims of physical assault, sexual assault, sexual molestation, domestic abuse, or elder or child abuse and neglect. (See also RI.01.06.03, EP 2)Note: Criteria can be based on age, sex, and circumstance.

EP 1


April 17, 2013




PC.01.02.11 The hospital assesses the needs of patients who receive psychosocial services to treat

alcoholism or other substance use disorders.

Patients receiving psychosocial services for the treatment of alcoholism or other substance use disorders receive an assessment that includes: The patient’s history of each substance use, including age of onset, duration, intensity, patterns of use, consequences of use, types of previous treatments, and responses to such treatment.

EP 1

Patients receiving psychosocial services for the treatment of alcoholism or other substance use disorders receive an assessment that includes: A history of the patient’s mental, emotional, and behavioral problems; their co-occurrence with substance use disorders; and their treatment.

EP 2

PC.01.02.13 The hospital assesses the needs of patients who receive treatment for emotional and

behavioral disorders.

Patients who receive treatment for emotional and behavioral disorders receive an assessment that includes a history of mental, emotional, behavioral, and substance use problems, their co-occurrence, and their treatment.

EP 1

Patients who receive treatment for emotional and behavioral disorders receive an assessment that includes the following: - Current mental, emotional, and behavioral functioning- Maladaptive or other behaviors that create a risk to the patient or others- Mental status examination- For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: Reason for admission as stated by the patient and/or others significantly involved in the patient’s care.

EP 2


and abilities.

The hospital performs a learning needs assessment for each patient, which includes the patient’s cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations, and barriers to communication.

EP 1






EP 12


patient.





EP 7


April 17, 2013





services.


EP 1


EP 2


EP 4



April 17, 2013




*D.

In this section, the NCQA standards address prompting patients to seek preventive care and chronic care as needed and contacting those patients not recently seen to make appointments. NCQA also requires organizations to follow up for care related to the use of selected medications. The patients to be prompted are identified through individual-specific information, clinical information, and practice guidelines. NCQA requires organizations to address at least three different types of preventive and three different types of chronic care.




EP 45





EP 1

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home provides disease and chronic care management services to its patients.

EP 3


EP 4


EP 5


April 17, 2013





services.


EP 2


April 17, 2013




III. Plan and Manage Care

A.

In this section, the NCQA standards address using evidence-based practice guidelines to remind patients about needed services when care is provided. NCQA states that this is applied to the first and second conditions, and third condition that may be related to health risk behaviors or substance abuse. These conditions are identified by the organization.

LD.04.04.07 The hospital considers clinical practice guidelines when designing or improving

processes.

The hospital considers using clinical practice guidelines when designing or improving processes. (See also NR.02.01.01, EP 5)

EP 1

When clinical practice guidelines will be used in the design or modification of processes, the hospital identifies criteria to guide their selection and implementation.

EP 2

The hospital manages and evaluates the implementation of the guidelines used in the design or modification of processes.

EP 3

The leaders of the hospital review and approve the clinical practice guidelines.EP 4

The organized medical staff reviews the clinical practice guidelines and modifies them as needed.EP 5


The hospital plans the patient’s care, treatment, and services based on needs identified by the patient’s assessment, reassessment, and results of diagnostic testing. (See also RC.02.01.01, EP 2)

EP 1

The written plan of care is based on the patient’s goals and the time frames, settings, and services required to meet those goals.Note: For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The patient’s goals include both short- and long-term goals.

EP 5

Based on the goals established in the patient’s plan of care, staff evaluate the patient’s progress.EP 22

The hospital revises plans and goals for care, treatment, and services based on the patient’s needs. (See also RC.02.01.01, EP 2)

EP 23

For hospitals that elect The Joint Commission Primary Care Medical Home option: Patient self-management goals are identified, agreed upon with the patient, and incorporated into the patient’s treatment plan. (Refer to RI.01.02.01, EP 1)

EP 44


EP 45


The hospital provides the patient with care, treatment, and services according to his or her individualized plan of care.

EP 1





EP 3


EP 4


April 17, 2013





EP 5

B.

In this section, the NCQA standards address creating criteria and procedures to identify patients with high risk or complex conditions, and determining how many such patients the organization serves.



EP 45





EP 5


services.


EP 1


April 17, 2013





EP 2

*C.

In this section, the NCQA standards state that at least 75% of the patients identified as having high risk or complex conditions, or who have conditions identified in A above, are informed about pre-visit preparations; participate in the development of their care plans (treatment goals are updated as needed); receive a plan of care in writing; are assessed for barriers when treatment goals are not met (the barriers are addressed); receive a care summary at the end of an appointment, as needed; and are assessed for the need for needed assistance in care management.

NCQA also requires that the organization follows up with at least 75% of the patients who have not kept appointments.




EP 23

PC.01.02.03 The hospital assesses and reassesses the patient and his or her condition according

to defined time frames.

Each patient is reassessed as necessary based on his or her plan for care or changes in his or her condition. Note: Reassessments may also be based on the patient's diagnosis; desire for care, treatment, and services; response to previous care, treatment, and services; and/or his or her setting requirements.

EP 3


The hospital plans the patient’s care, treatment, and services based on needs identified by the patient’s assessment, reassessment, and results of diagnostic testing. (See also RC.02.01.01, EP 2)

EP 1


EP 5



EP 23


April 17, 2013





EP 44


EP 45


The hospital provides the patient with care, treatment, and services according to his or her individualized plan of care.

EP 1


and abilities.


EP 1

The hospital provides education and training to the patient based on his or her assessed needs.EP 4

The hospital coordinates the patient education and training provided by all disciplines involved in the patient’s care, treatment, and services.

EP 5

Based on the patient’s condition and assessed needs, the education and training provided to the patient by the hospital include any of the following:- An explanation of the plan for care, treatment, and services- Basic health practices and safety- Information on the safe and effective use of medications (See also MM.06.01.01, EP 9; MM.06.01.03, EPs 3-6)- Nutrition interventions (for example, supplements) and modified diets- Discussion of pain, the risk for pain, the importance of effective pain management, the pain assessment process, and methods for pain management- Information on oral health- Information on the safe and effective use of medical equipment or supplies provided by the hospital- Habilitation or rehabilitation techniques to help the patient reach maximum independence- Fall reduction strategies

EP 10

The hospital evaluates the patient’s understanding of the education and training it provided.EP 25


EP 28


April 17, 2013








EP 5






EP 2


EP 6


EP 8


EP 9


EP 10

For hospitals that elect The Joint Commission Primary Care Medical Home option: The interdisciplinary team involves the patient in the development of his or her treatment plan.

EP 11


services.

For hospitals that elect The Joint Commission Primary Care Medical Home option: The medical record includes the patient’s self-management goals and the patient’s progress toward achieving those goals.

EP 29





April 17, 2013





EP 2


EP 3

RI.01.02.01 The hospital respects the patient's right to participate in decisions about his or her


Note: For hospitals that use Joint Commission accreditation for deemed status

purposes: This right is not to be construed as a mechanism to demand the provision of

treatment or services deemed medically unnecessary or inappropriate.

The hospital involves the patient in making decisions about his or her care, treatment, and services, including the right to have his or her own physician promptly notified of his or her admission to the hospital.

EP 1

The hospital involves the patient’s family in care, treatment, and services decisions to the extent permitted by the patient or surrogate decision-maker, in accordance with law and regulation.

EP 8

The hospital provides the patient or surrogate decision-maker with the information about the outcomes of care, treatment, and services that the patient needs in order to participate in current and future health care decisions.

EP 20

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home respects the patient’s right to make decisions about the management of his or her care.

EP 31



services.


EP 5

D.

In this section, the NCQA standards address meeting targets relative to medication management, specifically that in more than half of the episodes of care, medications are reviewed and reconciled for the patient and in more than 80% of the episodes of care, medications are reviewed and reconciled for the patient. NCQA also requires that more than 80% of patients are given information about newly prescribed medications. NCQA also requires organizations to assess patient understanding of medications, barriers to compliance, and patient response to medications for more than half of the patients. Organizations need to document the use of non-prescription medications for half of the patients.

NPSG.03.06.01 Maintain and communicate accurate patient medication information.

Obtain information on the medications the patient is currently taking when he or she is admitted to the hospital or is seen in an outpatient setting. This information is documented in a list or other format that is useful to those who manage medications. Note 1: Current medications include those taken at scheduled times and those taken on an as-needed basis. See the Glossary for a definition of medications. Note 2: It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information from the patient and/or other sources will be considered as meeting the intent of the EP.

EP 1


April 17, 2013




Define the types of medication information to be collected in non–24-hour settings and different patient circumstances. Note 1: Examples of non–24-hour settings include the emergency department, primary care, outpatient radiology, ambulatory surgery, and diagnostic settings. Note 2: Examples of medication information that may be collected include name, dose, route, frequency, and purpose.

EP 2

Compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital in order to identify and resolve discrepancies. Note: Discrepancies include omissions, duplications, contraindications, unclear information, and changes. A qualified individual, identified by the hospital, does the comparison. (See also HR.01.06.01, EP 1)

EP 3

Provide the patient (or family as needed) with written information on the medications the patient should be taking when he or she is discharged from the hospital or at the end of an outpatient encounter (for example, name, dose, route, frequency, purpose). Note: When the only additional medications prescribed are for a short duration, the medication information the hospital provides may include only those medications. For more information about communications to other providers of care when the patient is discharged or transferred, refer to Standard PC.04.02.01.

EP 4

Explain the importance of managing medication information to the patient when he or she is discharged from the hospital or at the end of an outpatient encounter. Note: Examples include instructing the patient to give a list to his or her primary care physician; to update the information when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication information at all times in the event of emergency situations. (For information on patient education on medications, refer to Standards MM.06.01.03, PC.02.03.01, and PC.04.01.05.)

EP 5

PC.02.01.21 The hospital effectively communicates with patients when providing care, treatment,

and services.

The hospital identifies the patient's oral and written communication needs, including the patient's preferred language for discussing health care. (See also RC.02.01.01, EP 1)Note: Examples of communication needs include the need for personal devices such as hearing aids or glasses, language interpreters, communication boards, and translated or plain language materials.

EP 1

The hospital communicates with the patient during the provision of care, treatment, and services in a manner that meets the patient's oral and written communication needs. (See also RI.01.01.03, EPs 1-3)

EP 2


patient’s needs.

For hospitals that elect The Joint Commission Primary Care Medical Home option: The interdisciplinary team identifies the patient's health literacy needs. Note: Typically this is an interactive process. For example, patients may be asked to demonstrate their understanding of information provided by explaining it in their own words.

EP 24

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care clinician and the interdisciplinary team incorporate the patient's health literacy needs into the patient's education.

EP 25


April 17, 2013





and abilities.


EP 1



EP 5


EP 10


The hospital provides the patient education on how to communicate concerns about patient safety issues that occur before, during, and after care is received.

EP 27


EP 28





EP 5


April 17, 2013




E.

In this section, the NCQA standards address using an electronic prescribing system that meets specific targets, including that at least 40% of relevant prescriptions are sent electronically to pharmacies and at least 75% of relevant prescriptions are generated electronically. NCQA standards state that electronic prescriptions are integrated into the patient’s health record, and that potential drug interactions are checked electronically. In the NCQA standards, the electronic prescribing system informs clinicians when generic drugs are available, and lets them know about the status of the medication in the organization’s formulary.

MM.02.01.01 The hospital selects and procures medications.

The hospital maintains a formulary, including medication strength and dosage. Note 1: Sample medications are not required to be on the formulary. Note 2: In some settings, the term "list of medications available for use" is used instead of “formulary.” The terms are synonymous.

EP 4

The hospital makes its formulary readily available to those involved in medication management.EP 5

MM.04.01.01 Medication orders are clear and accurate.

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home uses an electronic prescribing process.

EP 21



EP 45





EP 5


April 17, 2013




IV. Self-Care Support and Community

*A.

In this section, the NCQA standards address meeting targets relative to the patient’s management of his or her care, specifically that the organization gives or refers educational resources to at least half of the patients; works with at least half to the patients to develop self-management plans (these plans are documented); creates written assessments of self-management abilities for at least half of the patients; provides at least half of the patients with methods to record results of self-managed care; uses an electronic health record to identify educational resources for more than 10% of the patients (as needed); and advises at least half of the patients to adopt behaviors that protect their health.




EP 5



EP 23


EP 44


EP 45


and abilities.


EP 1



EP 10



EP 28


April 17, 2013








EP 5






EP 6


EP 9


EP 10


EP 11


EP 12


services.

For hospitals that elect The Joint Commission Primary Care Medical Home option: The medical record includes the patient’s self-management goals and the patient’s progress toward achieving those goals.

EP 29

B.

In this section, the NCQA standards address offering or referring patients to mental health or substance abuse services, as needed, and providing patient group support and educational resources. NCQA standards also require organizations to assist patients with access to community resources by creating a list of five community services that are relevant to the patients served and to monitor referrals provided to patients.


and abilities.


EP 5


April 17, 2013








EP 1


EP 3


EP 4


EP 5






EP 2


EP 6


April 17, 2013




V. Track and Coordinate Care

A.

In this section, the NCQA standards address monitoring all lab and imaging tests and following up on overdue results. NCQA standards state that electronic systems are used to order lab and imaging tests and obtain results, and that the relevant care providers are informed of any lab or imaging results that are not normal. NCQA also states that patients are notified of both normal and abnormal results.

The NCQA requirements also cover monitoring hearing and blood-spot screening done on newborns in hospitals. Imaging results and at least 40% of lab results are placed in the patient’s health record electronically. NCQA requires written procedures for the activities identified above, and demonstration that the organization follows those procedures.





EP 5






EP 6

For hospitals that elect The Joint Commission Primary Care Medical Home option: The interdisciplinary team acts on recommendations from internal and external referrals for additional care, treatment, or services.

EP 7


EP 9


April 17, 2013





services.


EP 2


EP 4

RI.01.02.01 The hospital respects the patient's right to participate in decisions about his or her


Note: For hospitals that use Joint Commission accreditation for deemed status

purposes: This right is not to be construed as a mechanism to demand the provision of

treatment or services deemed medically unnecessary or inappropriate.

The hospital provides the patient or surrogate decision-maker with the information about the outcomes of care, treatment, and services that the patient needs in order to participate in current and future health care decisions.

EP 20


April 17, 2013




*B.

In this section, the NCQA standards address activities related to referrals, specifically that the organization provides the clinician with the reason for referral and relevant patient information; establishes timeframes for receiving reports and monitors the status of referrals; and creates agreements with specialists when co-management of a patient is needed (this is documented in the patient’s health record). NCQA also requires that the organization obtains information from patients about self-referral, and acquires those results, and exchanges information electronically with other clinicians. The NCQA also requires an electronic summary of care provided is placed in more than half of the records of patients who were referred.


PC.02.01.05 The hospital provides interdisciplinary, collaborative care, treatment, and services.

Care, treatment, and services are provided to the patient in an interdisciplinary, collaborative manner.EP 1


patient’s needs.


EP 1


EP 2


EP 3


EP 10





EP 5






EP 2

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care clinician is responsible for making certain that the interdisciplinary team provides comprehensive and coordinated care, treatment, or services and maintains the continuity of care as described in EPs 6 through 13. Note: Coordination of care may include making internal and external referrals, developing and evaluating treatment plans, and resolving conflicts in the provision of care.

EP 5


April 17, 2013





EP 6


EP 7


EP 8


patient.





EP 7





EP 2


EP 3


EP 4



services.


EP 3


April 17, 2013





EP 5

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home provides information to the patient about: The patient’s right to obtain care from other clinicians within the primary care medical home, to seek a second opinion, and to seek specialty care. (Refer to PC.02.03.01, EP 4; RI.01.01.03, EPs 1 and 3)

EP 6

C.

In this section, the NCQA standards address identifying patients who were admitted to a hospital or made an ED visit, sharing patient information with the hospital or ED, and exchanging information for admitted patients. NCQA requires organizations to regularly obtain discharge summaries and contact the patient in a timely manner for follow up care. NCQA also expects the organization to exchange information electronically with other organizations, and provide a care summary to other organizations when there are transitions in care, for more than half of the patients. The organization works with the patient to create a care plan when the patient moves from pediatric to adult care.


The hospital defines, in writing, the scope and content of screening, assessment, and reassessment information it collects. (See also RC.02.01.01, EP 2)Note 1: In defining the scope and content of the information it collects, the organization may want to consider information that it can obtain, with the patient’s consent, from the patient’s family and the patient’s other care providers, as well as information conveyed on any medical jewelry.Note 2: Assessment and reassessment information includes the patient’s perception of the effectiveness of, and any side effects related to, his or her medication(s).

EP 1


EP 23


patient’s needs.


EP 1


EP 2


EP 3


EP 10


April 17, 2013








EP 1


EP 5






EP 2


EP 6


EP 7


EP 9


EP 11


April 17, 2013




PC.04.02.01 When a patient is discharged or transferred, the hospital gives information about the

care, treatment, and services provided to the patient to other service providers who

will provide the patient with care, treatment, or services.

At the time of the patient’s discharge or transfer, the hospital informs other service providers who will provide care, treatment, or services to the patient about the following:- The reason for the patient’s discharge or transfer- The patient’s physical and psychosocial status- A summary of care, treatment, and services it provided to the patient- The patient’s progress toward goals- A list of community resources or referrals made or provided to the patient (See also PC.02.02.01, EP 1)

EP 1


patient.




EP 7

The medical record contains information about the patient’s care, treatment, or services that promotes continuity of care among providers. Note: For hospitals that elect The Joint Commission Primary Care Medical Home option: This requirement refers to care provided by both internal and external providers.

EP 8

The hospital assembles or makes available in a summary in the medical record all information required to provide patient care, treatment, and services. (See also MM.01.01.01, EP 1)

EP 13





EP 2


EP 3


EP 4


April 17, 2013




VI. Measure and Improve Performance

A.

In this section, the NCQA standards address collecting data on preventive care (at least three measures), chronic or acute care (at least three measures), and utilization and cost (two measures). NCQA requires organizations to analyze data to identify whether there are differences in care provided to specific populations.

APR.04.01.01 The hospital selects and uses core performance measure sets and/or non-core

performance measures from among those available through its listed ORYX® vendor.

Note 1: If core measures are not applicable, the hospital identifies clinical measures

based on current ORYX® requirements.

Note 2: Hospitals are encouraged to keep up-to-date on any changes in the ORYX®

requirements by reviewing recent issues of The Joint Commission Perspectives® or by

going to the "Performance Measurement" area on The Joint Commission website at

http://www.jointcommission.org.

The hospital selects a sufficient number of core performance measure sets and/or non-core performance measures to meet current ORYX® requirements.

EP 11

The hospital uses each individual core measure set and/or non-core measure for at least four consecutive quarters before replacing it.

EP 18

For the most recent 12-month reporting period, the hospital achieves and sustains an acceptable level of performance, as defined by quarterly Joint Commission statistical analysis, for each core measure within a measure set and/or each non-core measure before it discontinues its use of such a measure set.

EP 24

LD.04.04.01 Leaders establish priorities for performance improvement. (Refer to the "Performance

Improvement" [PI] chapter.)

Leaders set priorities for performance improvement activities and patient health outcomes. (See also PI.01.01.01, EPs 1 and 3)

EP 1

Leaders give priority to high-volume, high-risk, or problem-prone processes for performance improvement activities. (See also PI.01.01.01, EPs 4, 6-8, 11-12, and 14-15)

EP 2


The leaders set priorities for data collection. (See also LD.04.04.01, EP 1)EP 1

The leaders identify the frequency for data collection.Note: For hospitals that use Joint Commission accreditation for deemed status purposes: The leaders that specify the frequency and detail of data collection is the governing body.

EP 2

The hospital collects data on the following: Performance improvement priorities identified by leaders. (See also LD.04.04.01, EP 1)

EP 3

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home collects data on the following: Disease management outcomes.

EP 40

PI.02.01.01 The hospital compiles and analyzes data.

The hospital compiles data in usable formats.EP 1

The hospital identifies the frequency for data analysis.EP 2

The hospital analyzes and compares internal data over time to identify levels of performance, patterns, trends, and variations.

EP 4

The hospital compares data with external sources, when available.EP 5


April 17, 2013




The hospital uses the results of data analysis to identify improvement opportunities. (See also LD.03.02.01, EP 5; PI.03.01.01, EP 1)

EP 8

PI.02.01.03 The hospital improves its performance on ORYX® accountability measures.

The hospital achieves a composite performance rate of at least 85% on the ORYX® accountability measures transmitted to The Joint Commission.Note: For more information, refer to the "Performance Measurement" (PM) chapter.

EP 1


services.


EP 1


EP 2



April 17, 2013




B.

In this section, the NCQA standards address collecting data from the patient (including patients from vulnerable groups) on his or her experience with care in at least three of the following categories: access, communication, coordination, and care of the whole person. NCQA requires the organization uses the CAHPS survey instrument and qualitative methods to collect this information.




EP 20



For hospitals that elect The Joint Commission Primary Care Medical Home option: Leaders involve patients in performance improvement activities. Note: Patient involvement may include activities such as participating on a quality committee or providing feedback on safety and quality issues.

EP 24




EP 2

The hospital collects data on the following: Patient perception of the safety and quality of care, treatment, or services.

EP 16

For hospitals that elect The Joint Commission Primary Care Medical Home option: The primary care medical home collects data on the following: - Patient experience and satisfaction related to access to care, treatment, or services, and communication - Patient perception of the comprehensiveness of care, treatment, or services - Patient perception of the coordination of care, treatment, or services - Patient perception of the continuity of care, treatment, or services(Refer to PI.01.01.01, EP 16)

EP 42





EP 4



EP 8


April 17, 2013





services.


EP 1


EP 2


*C.

In this section, the NCQA standards address using performance improvement methods to improve results from at least three measures from section A and one from section B. When there are disparities in care for certain populations, improvement efforts are initiated for at least one disparity. NCQA also requires that patients are involved in performance improvement activities.




Leaders set priorities for performance improvement activities and patient health outcomes. (See also PI.01.01.01, EPs 1 and 3)

EP 1

Leaders give priority to high-volume, high-risk, or problem-prone processes for performance improvement activities. (See also PI.01.01.01, EPs 4, 6-8, 11-12, and 14-15)

EP 2

Leaders reprioritize performance improvement activities in response to changes in the internal or external environment.

EP 3


April 17, 2013




For hospitals that elect The Joint Commission Primary Care Medical Home option: Ongoing performance improvement occurs hospital-wide for the purpose of demonstrably improving the quality and safety of care, treatment, or services.

EP 5

For hospitals that elect The Joint Commission Primary Care Medical Home option: Leaders involve patients in performance improvement activities. Note: Patient involvement may include activities such as participating on a quality committee or providing feedback on safety and quality issues.

EP 24





For hospitals that elect The Joint Commission Primary Care Medical Home option: The interdisciplinary team actively participates in performance improvement activities.

EP 13





EP 4



EP 8


Leaders prioritize the identified improvement opportunities. (See also PI.02.01.01, EP 8; MS.05.01.01, EPs 1-11)

EP 1

The hospital takes action on improvement priorities. (See also MS.05.01.01, EPs 1-11)EP 2

The hospital evaluates actions to confirm that they resulted in improvements. (See also MS.05.01.01, EPs 1-11)

EP 3

The hospital takes action when it does not achieve or sustain planned improvements. (See also MS.05.01.01, EPs 1-11)

EP 4


EP 11


April 17, 2013





services.


EP 1


EP 2


D.

In this section, the NCQA standards address evaluating the effectiveness of processes by assessing results, the effectiveness of improvements, and achieving improved performance on two measures.




EP 20



For hospitals that elect The Joint Commission Primary Care Medical Home option: Ongoing performance improvement occurs hospital-wide for the purpose of demonstrably improving the quality and safety of care, treatment, or services.

EP 5


April 17, 2013







EP 2

The hospital collects data on the following: Performance improvement priorities identified by leaders. (See also LD.04.04.01, EP 1)

EP 3




The hospital uses statistical tools and techniques to analyze and display data.EP 3


EP 4



EP 8

PI.02.01.03 The hospital improves its performance on ORYX® accountability measures.

The hospital achieves a composite performance rate of at least 85% on the ORYX® accountability measures transmitted to The Joint Commission.Note: For more information, refer to the "Performance Measurement" (PM) chapter.

EP 1


Leaders prioritize the identified improvement opportunities. (See also PI.02.01.01, EP 8; MS.05.01.01, EPs 1-11)

EP 1

The hospital takes action on improvement priorities. (See also MS.05.01.01, EPs 1-11)EP 2

The hospital evaluates actions to confirm that they resulted in improvements. (See also MS.05.01.01, EPs 1-11)

EP 3

The hospital takes action when it does not achieve or sustain planned improvements. (See also MS.05.01.01, EPs 1-11)

EP 4


EP 11


April 17, 2013




E.

In this section, the NCQA standards address sharing the results of data measurement (sections A and B) internally, and stratifying them by individual clinician and aggregating them across the organization. This information is also given to patients or the public.

APR.09.03.01 The hospital is truthful and accurate when describing information in its Quality Report

to the public.

The hospital adheres to The Joint Commission’s published guidelines for how it describes information in its Quality Report.

EP 1


formats.

The hospital has written policies addressing data capture, display, transmission, and retention.EP 1


EP 2

The hospital disseminates data and information in useful formats within time frames that are defined by the hospital and consistent with law and regulation.

EP 3

LD.02.03.01 The governing body, senior managers and leaders of the organized medical staff

regularly communicate with each other on issues of safety and quality.

Leaders discuss issues that affect the hospital and the population(s) it serves, including the following:- Performance improvement activities- Reported safety and quality issues- Proposed solutions and their impact on the hospital’s resources- Reports on key quality measures and safety indicators- Safety and quality issues specific to the population served- Input from the population(s) served(See also NR.01.01.01, EP 3)

EP 1

LD.03.04.01 The hospital communicates information related to safety and quality to those who need

it, including staff, licensed independent practitioners, patients, families, and external

interested parties.

Communication processes foster the safety of the patient and the quality of care.EP 1

Communication is designed to meet the needs of internal and external users.EP 3

Leaders provide the resources required for communication, based on the needs of patients, the community, physicians, staff, and management.

EP 4

Communication supports safety and quality throughout the hospital. (See also LD.04.04.05, EPs 6 and 12)

EP 5

MS.05.01.03 The organized medical staff participates in organization-wide performance

improvement activities.

The organized medical staff participates in the following activities: Review of findings of the assessment process that are relevant to an individual’s performance. The organized medical staff is responsible for determining the use of this information in the ongoing evaluations of a practitioner’s competence.

EP 4

The organized medical staff participates in the following activities: Communication of findings, conclusions, recommendations, and actions to improve performance to appropriate staff members and the governing body.

EP 5


April 17, 2013




MS.08.01.01 The organized medical staff defines the circumstances requiring monitoring and

evaluation of a practitioner’s professional performance.

A period of focused professional practice evaluation is implemented for all initially requested privileges.EP 1

The organized medical staff develops criteria to be used for evaluating the performance of practitioners when issues affecting the provision of safe, high quality patient care are identified.

EP 2

The performance monitoring process is clearly defined and includes each of the following elements:- Criteria for conducting performance monitoring- Method for establishing a monitoring plan specific to the requested privilege- Method for determining the duration of performance monitoring- Circumstances under which monitoring by an external source is required

EP 3

Focused professional practice evaluation is consistently implemented in accordance with the criteria and requirements defined by the organized medical staff.

EP 4

The triggers that indicate the need for performance monitoring are clearly defined. Note: Triggers can be single incidents or evidence of a clinical practice trend.

EP 5

The decision to assign a period of performance monitoring to further assess current competence is based on the evaluation of a practitioner’s current clinical competence, practice behavior, and ability to perform the requested privilege. Note: Other existing privileges in good standing should not be affected by this decision.

EP 6

Criteria are developed that determine the type of monitoring to be conducted.EP 7

The measures employed to resolve performance issues are clearly defined.EP 8

The measures employed to resolve performance issues are consistently implemented.EP 9

MS.08.01.03 Ongoing professional practice evaluation information is factored into the decision to

maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing

privilege prior to or at the time of renewal.

The process for the ongoing professional practice evaluation includes the following: There is a clearly defined process in place that facilitates the evaluation of each practitioner’s professional practice.

EP 1

The process for the ongoing professional practice evaluation includes the following: The type of data to be collected is determined by individual departments and approved by the organized medical staff.

EP 2

The process for the ongoing professional practice evaluation includes the following: Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege(s).

EP 3


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EP 5

F.

In this section, the NCQA standards address reporting measures electronically to CMS, data to immunization registries, and syndrome information to public health agencies.

APR.04.01.01 The hospital selects and uses core performance measure sets and/or non-core

performance measures from among those available through its listed ORYX® vendor.

Note 1: If core measures are not applicable, the hospital identifies clinical measures

based on current ORYX® requirements.

Note 2: Hospitals are encouraged to keep up-to-date on any changes in the ORYX®

requirements by reviewing recent issues of The Joint Commission Perspectives® or by

going to the "Performance Measurement" area on The Joint Commission website at

http://www.jointcommission.org.

The hospital allows the ORYX® vendor to submit hospital clinical data to The Joint Commission at least four times a year.

EP 22

IC.02.01.01 The hospital implements its infection prevention and control plan.

The hospital reports infection surveillance, prevention, and control information to local, state, and federal public health authorities in accordance with law and regulation. (See also IC.01.05.01, EP 8)

EP 9


formats.

The hospital has written policies addressing data capture, display, transmission, and retention.EP 1


EP 2

The hospital disseminates data and information in useful formats within time frames that are defined by the hospital and consistent with law and regulation.

EP 3


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EP 5


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