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Hospital and Critical Access Hospital (HAP/CAH) Accreditation

The Joint Commission

Hospital and Critical Access Hospital (HAP/CAH) Accreditation

Topics Covered in this section:

  • Chart-abstracted Measures (CAM)

  • Electronic Clinical Quality Measure (eCQM)


CHART-ABSTRACTED MEASURES

Resource Title: American College of Emergency Physicians (ACEP), Emergency Department Crowding: High Impact Solutions

Link: https://www.acep.org/globalassets/sites/acep/media/crowding/empc_crowding-ip_092016.pdf

Resource Title: American College of Emergency Physicians (ACEP), Emergency Department Crowding: High Impact Solutions

Link: https://www.acep.org/globalassets/sites/acep/media/crowding/empc_crowding-ip_092016.pdf

Resource Title: Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals

Link: https://www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf

 

Resource Title: Emergency Department Quality Improvement: Transforming the Delivery of Care

Link: https://www.healthcatalyst.com/insights/emergency-department-quality-improvement-transforming-delivery-care

Resource Title: Emergency Department Quality Improvement: Transforming the Delivery of Care

Link: https://www.healthcatalyst.com/insights/emergency-department-quality-improvement-transforming-delivery-care

Resource Title: National Center for Health Statistics National Hospital Ambulatory Survey: 2020 Emergency Department Summary Tables

Link: https://www.cdc.gov/nchs/data/nhamcs/web_tables/2020-nhamcs-ed-web-tables-508.pdf

 

Resource Title: APNA Standards of Practice: Seclusion and Restraint

Link: https://www.apna.org/standards-of-practice-seclusion-and-restraint/

Resource Title: APNA Standards of Practice: Seclusion and Restraint

Link: https://www.apna.org/standards-of-practice-seclusion-and-restraint/

 

Resource Title: APA Resource Document Outlines Principles on Use of Seclusion, Restraint

Link: http://apapsy.ch/S-R

Resource Title: APA Resource Document Outlines Principles on Use of Seclusion, Restraint

Link: http://apapsy.ch/S-R

 

Resource Title: CDC Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2024-25

Link: https://www.cdc.gov/flu/hcp/acip/index.html

Resource Title: CDC Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2024-25

Link: https://www.cdc.gov/flu/hcp/acip/index.html

Resource Title: National Adult and Influenza Immunization Summit: Influenza Vaccination Resources

Link: https://www.izsummitpartners.org/influenza-vaccination-resources/

 

Resource Title: AHRQ Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals

Link: https://www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf

Resource Title: AHRQ Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals

Link: https://www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf

Resource Title: American College of Emergency Physicians Approaching Full Capacity in the Emergency Department

Link: https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/crowding/approach_full_capacity.pdf

 

Resource Title: California Maternal Quality Care Collaborative (CMQCC) toolkit-Elimination of Nonmedically Indicated Early Deliveries

Link: https://www.cmqcc.org/resources-tool-kits/toolkits/early-elective-deliveries-toolkit

Resource Title: California Maternal Quality Care Collaborative (CMQCC) toolkit-Elimination of Nonmedically Indicated Early Deliveries

Link: https://www.cmqcc.org/resources-tool-kits/toolkits/early-elective-deliveries-toolkit

Resource Title: National Quality Forum (NQF) Early Elective Delivery Playbook - Maternity Action Team

Link: https://www.qualityforum.org/Publications/2014/08/Playbook_for_the_Successful_Elimination_of_Early_Elective_Deliveries.aspx

 

Resource Title: California Maternal Quality Care Collaborative (CMQCC) - Supporting Vaginal Birth

Link: https://www.cmqcc.org/quality-improvement-toolkits/supporting-vaginal-birth

Resource Title: California Maternal Quality Care Collaborative (CMQCC) - Supporting Vaginal Birth

Link: https://www.cmqcc.org/quality-improvement-toolkits/supporting-vaginal-birth

Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes

Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks

 

Resource Title: The Centers for Disease Control and Prevention (CDC) Guide-Breastfeeding Resource Library

Link: https://www.cdc.gov/breastfeeding/

Resource Title: The Centers for Disease Control and Prevention (CDC) Guide-Breastfeeding Resource Library

Link: https://www.cdc.gov/breastfeeding/

Resource Title: The United States Breastfeeding Committee toolkit

Link: http://www.usbreastfeeding.org/

 

Resource Title: The California Maternal Quality Care Collaborative (CMQCC) QI Toolkits

Link: https://cpqcc.org/resource-categories/qi-toolkits?page=1

Resource Title: The California Maternal Quality Care Collaborative (CMQCC) QI Toolkits

Link: https://cpqcc.org/resource-categories/qi-toolkits?page=1

Resource Title: Centers for Disease Control and Prevention (CDC) Infant Mortality

Link: https://www.cdc.gov/maternal-infant-health/infant-mortality/?CDC_AAref_Val=https://www.cdc.gov/reproductivehealth/MaternalInfantHealth/InfantMortality.htm

 

Resource Title: The Joint Commission Health Care Equity Accreditation Resource Center

Link: https://www.jointcommission.org/our-priorities/health-care-equity/accreditation-resource-center/

Resource Title: The Joint Commission Health Care Equity Accreditation Resource Center

Link: https://www.jointcommission.org/our-priorities/health-care-equity/accreditation-resource-center/

 

Resource Title: The Joint Commission Health Care Equity Accreditation Resource Center

Link: https://www.jointcommission.org/our-priorities/health-care-equity/accreditation-resource-center/

Resource Title: The Joint Commission Health Care Equity Accreditation Resource Center

Link: https://www.jointcommission.org/our-priorities/health-care-equity/accreditation-resource-center/

 

Resource Title: SAMHSA: Screening, Brief Intervention, and Referral to Treatment

Link: https://www.samhsa.gov/sbirt

Resource Title: SAMHSA: Screening, Brief Intervention, and Referral to Treatment

Link: https://www.samhsa.gov/sbirt

 

Resource Title: The American Psychiatric Association Practice Guideline For The Pharmacological Treatment Of Patients With Alcohol Use Disorder

Link: https://doi.org/10.1176/appi.books.9781615371969

Resource Title: The American Psychiatric Association Practice Guideline For The Pharmacological Treatment Of Patients With Alcohol Use Disorder

Link: https://doi.org/10.1176/appi.books.9781615371969

 

Resource Title: 2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment 

A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents 

Link: https://www.jacc.org/doi/10.1016/j.jacc.2018.10.027

Resource Title: 2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment 

A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents 

Link: https://www.jacc.org/doi/10.1016/j.jacc.2018.10.027

Resource Title: Tobacco Cessation Interventions and Smoke-Free Policies in Mental Health and Substance Abuse Treatment Facilities — United States, 2016

Link: https://www.cdc.gov/mmwr/volumes/67/wr/mm6718a3.htm

Resource Title: Tobacco Cessation Interventions and Smoke-Free Policies in Mental Health and Substance Abuse Treatment Facilities — United States, 2016

Link: https://www.cdc.gov/mmwr/volumes/67/wr/mm6718a3.htm

Resource Title: Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement (2nd Edition, August 2016)

Link: https://www.ahrq.gov/sites/default/files/publications/files/vteguide.pdf

Resource Title: Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement (2nd Edition, August 2016)

Link: https://www.ahrq.gov/sites/default/files/publications/files/vteguide.pdf

Resource Title: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines: Executive Summary

Link: https://journal.chestnet.org/article/S0012-3692(12)60114-7/pdf

Resource Title: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines: Executive Summary

Link: https://journal.chestnet.org/article/S0012-3692(12)60114-7/pdf

Electronic Clinical Quality Measures (eCQMs)

Resource Title: Commission on Dietetic Registration- Global Malnutrition Composite Score: Free Educational Resources

Link: https://www.cdrnet.org/GMCS

Resource Title: Commission on Dietetic Registration- Global Malnutrition Composite Score: Free Educational Resources

Link: https://www.cdrnet.org/GMCS

 

Resource Title: ADA: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020

Link: https://diabetesjournals.org/care/article/43/Supplement_1/S193/30405/15-Diabetes-Care-in-the-Hospital-Standards-of

Resource Title: ADA: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020

Link: https://diabetesjournals.org/care/article/43/Supplement_1/S193/30405/15-Diabetes-Care-in-the-Hospital-Standards-of

 

Resource Title: ADA: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020

Link: https://diabetesjournals.org/care/article/43/Supplement_1/S193/30405/15-Diabetes-Care-in-the-Hospital-Standards-of

Resource Title: ADA: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020

Link: https://diabetesjournals.org/care/article/43/Supplement_1/S193/30405/15-Diabetes-Care-in-the-Hospital-Standards-of

 

Resource Title: Society of Hospital Medicine: Opioid Safety

Link: https://www.hospitalmedicine.org/clinical-topics/opioid-safety/

Resource Title: Society of Hospital Medicine: Opioid Safety

Link: https://www.hospitalmedicine.org/clinical-topics/opioid-safety/

 

Resource Title: AHA/ASA Journals: 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

Link: https://www.ahajournals.org/doi/10.1161/CIR.0b013e3182742cf6

Resource Title: AHA/ASA Journals: 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

Link: https://www.ahajournals.org/doi/10.1161/CIR.0b013e3182742cf6

Resource Title: AHA/ASA Journals: Association Between 90-Minute Door-to-Balloon Time, Selective Exclusion of Myocardial Infarction Cases, and Access Site Choice

Link: https://www.ahajournals.org/doi/10.1161/CIRCINTERVENTIONS.120.009179

Resource Title: AHA/ASA Journals: Association Between 90-Minute Door-to-Balloon Time, Selective Exclusion of Myocardial Infarction Cases, and Access Site Choice

Link: https://www.ahajournals.org/doi/10.1161/CIRCINTERVENTIONS.120.009179

 

Resource Title: California Maternal Quality Care Collaborative (CMQCC) toolkit-Elimination of Nonmedically Indicated Early Deliveries

Link: https://www.cmqcc.org/resources-tool-kits/toolkits/early-elective-deliveries-toolkit

Resource Title: California Maternal Quality Care Collaborative (CMQCC) toolkit-Elimination of Nonmedically Indicated Early Deliveries

Link: https://www.cmqcc.org/resources-tool-kits/toolkits/early-elective-deliveries-toolkit

Resource Title: National Quality Forum (NQF) Early Elective Delivery Playbook - Maternity Action Team

Link: https://www.qualityforum.org/Publications/2014/08/Playbook_for_the_Successful_Elimination_of_Early_Elective_Deliveries.aspx

Resource Title: National Quality Forum (NQF) Early Elective Delivery Playbook - Maternity Action Team

Link: https://www.qualityforum.org/Publications/2014/08/Playbook_for_the_Successful_Elimination_of_Early_Elective_Deliveries.aspx

 

Resource Title: California Maternal Quality Care Collaborative (CMQCC) - Supporting Vaginal Birth

Link: https://www.cmqcc.org/quality-improvement-toolkits/supporting-vaginal-birth

Resource Title: California Maternal Quality Care Collaborative (CMQCC) - Supporting Vaginal Birth

Link: https://www.cmqcc.org/quality-improvement-toolkits/supporting-vaginal-birth

Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes

Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks

Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes

Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks

Resource Title: The Centers for Disease Control and Prevention (CDC) Guide-Breastfeeding Resource Library

Link: https://www.cdc.gov/breastfeeding/

Resource Title: The Centers for Disease Control and Prevention (CDC) Guide-Breastfeeding Resource Library

Link: https://www.cdc.gov/breastfeeding/

Resource Title: The United States Breastfeeding Committee toolkit

Link: https://www.usbreastfeeding.org/publications.html

Resource Title: The United States Breastfeeding Committee toolkit

Link: https://www.usbreastfeeding.org/publications.html

Resource Title: The California Maternal Quality Care Collaborative (CMQCC) QI Toolkits

Link: https://cpqcc.org/resource-categories/qi-toolkits?page=1

Resource Title: The California Maternal Quality Care Collaborative (CMQCC) QI Toolkits

Link: https://cpqcc.org/resource-categories/qi-toolkits?page=1

Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes

Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks

Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes

Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks

 

Resource Title: American Hospital Association Maternal and Child Health Tools and Resources

Link: https://www.aha.org/maternal-child-health-tools-resources

Resource Title: American Hospital Association Maternal and Child Health Tools and Resources

Link: https://www.aha.org/maternal-child-health-tools-resources

Resource Title: Alliance for Innovation on Maternal Health

Link: https://saferbirth.org/

Resource Title: Alliance for Innovation on Maternal Health

Link: https://saferbirth.org/

Resource Title: Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Link: https://www.ahajournals.org/doi/10.1161/str.0000000000000024

Resource Title: Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Link: https://www.ahajournals.org/doi/10.1161/str.0000000000000024

Resource Title: 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack From the American Heart Association/American Stroke Association

Link: https://www.ahajournals.org/doi/pdf/10.1161/STR.0000000000000375

Resource Title: 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack From the American Heart Association/American Stroke Association

Link: https://www.ahajournals.org/doi/pdf/10.1161/STR.0000000000000375

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Resource Title: CDC: Overdose Prevention

Link: https://www.cdc.gov/overdose-prevention/index.html

Resource Title: CDC: Overdose Prevention

Link: https://www.cdc.gov/overdose-prevention/index.html

 

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