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Joint Commission Measures

The Joint Commission, an independent, not-for-profit organization responsible for accreditation of health-care organizations and programs in the United States, has developed new voluntary performance measures for hospitals for assessing and treating tobacco dependence in all hospitalized patients.

This new measure set replaces the current National Hospital Quality Measures for Adult Smoking Cessation Advice/Counseling in the acute myocardial infarction (AMI-4), heart failure (HF-4), and pneumonia (PN-4). Unlike the earlier measures which applied only to three specific diagnoses, the scope of the new measure set has been expanded to apply to all hospitalized patients 18 years of age and older. Note: The Meaningful Use core measure requires screening and documentation in the Electronic Health Record of the smoking status of all patients 13 years of age.

Additional details about this measure set are available in “Specifications Manual for National Hospital Inpatient Quality Measures” on the Joint Commission website.

The Partnership for Prevention funded development of the new Joint Commission tobacco measure set and has also prepared a guide for hospitals on the new tobacco measure set.

To hear the Joint Commission Project Manager, Nancy Lawler and Dr. Nancy Rigotti, Massachusetts General Hospital discuss the tobacco measures, watch the Action to Quit webinar.

What does the future hold for the Joint Commission tobacco measure set? CMS has proposed rule changes for their Inpatient Prospective Payment System (IPPS) which would include tobacco measures in 2015. Partnership for Prevention and partner organizations have sent a letter to CMS to encourge inclusion of the Joint Commission tobacco measures in the IPPS and the Inpatient Quality Reporting (IQR) Program now, rather than 2015. Adding a tobacco cessation measure to the Inpatient Quality Reporting (IQR) Program will make this measure eligible for inclusion in the new Hospital Value-Based Purchasing (VBP) Program. Under the VBP program, hospitals will have an incentive to not only report selected quality measures but to perform well on them. Public comment was submitted by the Partnership for Prevention and by the Multi-State Collaborative.

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