The Joint Commission

Percentage of acute myocardial infarction (AMI) patients who expired during hospital stay.

Proportion of heart failure patients age 18 and older with LVSD for whom beta-blocker therapy (i.e., bisoprolol, carvedilol, or sustained-release metoprolol succinate) is prescribed at discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.

Use of relievers in pediatric patients, age 2 years through 17 years, admitted for inpatient treatment of asthma. This measure is a part of a set of three nationally implemented measures that address children’s asthma care (CAC-2: Systemic Corticosteroids for Inpatient Asthma, and CAC-03: Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver) that are used in The Joint Commission’s accreditation process.

Use of systemic corticosteroids in pediatric asthma patients (age 2 through 17 years) admitted for inpatient treatment of asthma. This measure is a part of a set of three nationally implemented measures that address children’s asthma care (CAC-1: Relievers for Inpatient Asthma, CAC-3: Home Management Plan of Care (HMPC) Document Given to Parent/Caregiver) that are used in The Joint Commission’s accreditation process.

This measure assesses the proportion of pediatric asthma patients discharged from an inpatient hospital stay with a Home Management Plan of Care (HMPC) document in place. This measure is one of a set of three nationally implemented measures that address children’s asthma care (CAC-1: Relievers for Inpatient Asthma, and CAC-2: Systemic Corticosteroids for Inpatient Asthma) that are used in The Joint Commission’s accreditation process.

Proportion of ischemic stroke patients age 18 years or older for whom an initial NIHSS score is performed prior to any acute recanalization therapy (i.e., intra-venous (IV) thrombolytic (t-PA) therapy, or intra-arterial (IA) thrombolytic (t-PA) therapy, or mechanical endovascular reperfusion (MER) therapy) in patients undergoing recanalization therapy and documented in the medical record, or documented within 12 hours of arrival at the hospital emergency department in patients who do not undergo recanalization therapy.

Proportion of SAH and ICH stroke patients age 18 years or older for whom a severity measurement (i.e., Hunt and Hess Scale for SAH patients or ICH Score for ICH patients) is performed prior to surgical intervention (e.g., clipping, coiling, or any surgical intervention) in patients undergoing surgical intervention and documented in the medical record; OR, documented within 6 hours of arrival at the hospital emergency department in patients who do not undergo surgical intervention.

Proportion of subarachnoid hemorrhage (SAH) patients age 18 years and older for whom nimodipine treatment was administered within 24 hours of arrival at this hospital.

This is the sixth measure in a set of measures developed for Joint Commission Comprehensive Stroke Certification. Although it is not required that these measures are reported in conjunction with each other, The Joint Commission develops measures in sets in order to provide as comprehensive a view of quality for a particular clinical topic as possible.

This measure assesses the number of nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth.  

Hospital-level measure scores are calculated as a risk-adjusted proportion of the number of delivery hospitalizations for women who experience a severe obstetric complication, as defined by the numerator, by the total number of delivery hospitalizations in the denominator during the measurement period.