The Joint Commission
Hospital and Critical Access Hospital (HAP/CAH) Accreditation
Kelly C
bwamhoff
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 |
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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 |
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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 |
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Resource Title: Emergency Department Quality Improvement: Transforming the Delivery of Care |
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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/ |
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Resource Title: APNA Standards of Practice: Seclusion and Restraint Link: https://www.apna.org/standards-of-practice-seclusion-and-restraint/ |
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Resource Title: APA Resource Document Outlines Principles on Use of Seclusion, Restraint Link: http://apapsy.ch/S-R |
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Resource Title: APA Resource Document Outlines Principles on Use of Seclusion, Restraint Link: http://apapsy.ch/S-R |
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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 |
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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 |
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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 |
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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 |
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Resource Title: American College of Emergency Physicians Approaching Full Capacity in the Emergency Department |
Resource Title: American Heart Association Target: Stroke Direct to CT/MRI Protocol |
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Resource Title: American Heart Association Target: Stroke Direct to CT/MRI Protocol |
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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 |
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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 |
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Resource Title: National Quality Forum (NQF) Early Elective Delivery Playbook - Maternity Action Team |
Resource Title: California Maternal Quality Care Collaborative (CMQCC) - Supporting Vaginal Birth Link: https://www.cmqcc.org/quality-improvement-toolkits/supporting-vaginal-birth |
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Resource Title: California Maternal Quality Care Collaborative (CMQCC) - Supporting Vaginal Birth Link: https://www.cmqcc.org/quality-improvement-toolkits/supporting-vaginal-birth |
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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/ |
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Resource Title: The Centers for Disease Control and Prevention (CDC) Guide-Breastfeeding Resource Library Link: https://www.cdc.gov/breastfeeding/ |
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Resource Title: The United States Breastfeeding Committee toolkit |
Resource Title: The California Maternal Quality Care Collaborative (CMQCC) QI Toolkits Link: https://cpqcc.org/resource-categories/qi-toolkits?page=1 |
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Resource Title: The California Maternal Quality Care Collaborative (CMQCC) QI Toolkits Link: https://cpqcc.org/resource-categories/qi-toolkits?page=1 |
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Resource Title: Centers for Disease Control and Prevention (CDC) Infant Mortality |
Resource Title: The Joint Commission Health Care Equity Accreditation Resource Center Link: https://www.jointcommission.org/our-priorities/health-care-equity/accreditation-resource-center/ |
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Resource Title: The Joint Commission Health Care Equity Accreditation Resource Center Link: https://www.jointcommission.org/our-priorities/health-care-equity/accreditation-resource-center/ |
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Resource Title: The Joint Commission Health Care Equity Accreditation Resource Center Link: https://www.jointcommission.org/our-priorities/health-care-equity/accreditation-resource-center/ |
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Resource Title: The Joint Commission Health Care Equity Accreditation Resource Center Link: https://www.jointcommission.org/our-priorities/health-care-equity/accreditation-resource-center/ |
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Resource Title: SAMHSA: Screening, Brief Intervention, and Referral to Treatment Link: https://www.samhsa.gov/sbirt |
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Resource Title: SAMHSA: Screening, Brief Intervention, and Referral to Treatment Link: https://www.samhsa.gov/sbirt |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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Electronic Clinical Quality Measures (eCQMs)
Resource Title: Commission on Dietetic Registration- Global Malnutrition Composite Score: Free Educational Resources Link: https://www.cdrnet.org/GMCS |
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Resource Title: Commission on Dietetic Registration- Global Malnutrition Composite Score: Free Educational Resources Link: https://www.cdrnet.org/GMCS |
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Resource Title: ADA: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020 |
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Resource Title: ADA: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020 |
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Resource Title: ADA: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020 |
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Resource Title: ADA: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020 |
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Resource Title: Society of Hospital Medicine: Opioid Safety Link: https://www.hospitalmedicine.org/clinical-topics/opioid-safety/ |
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Resource Title: Society of Hospital Medicine: Opioid Safety Link: https://www.hospitalmedicine.org/clinical-topics/opioid-safety/ |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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Resource Title: National Quality Forum (NQF) Early Elective Delivery Playbook - Maternity Action Team |
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Resource Title: National Quality Forum (NQF) Early Elective Delivery Playbook - Maternity Action Team |
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Resource Title: California Maternal Quality Care Collaborative (CMQCC) - Supporting Vaginal Birth Link: https://www.cmqcc.org/quality-improvement-toolkits/supporting-vaginal-birth |
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Resource Title: California Maternal Quality Care Collaborative (CMQCC) - Supporting Vaginal Birth Link: https://www.cmqcc.org/quality-improvement-toolkits/supporting-vaginal-birth |
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Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks |
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Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks |
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Resource Title: The Centers for Disease Control and Prevention (CDC) Guide-Breastfeeding Resource Library Link: https://www.cdc.gov/breastfeeding/ |
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Resource Title: The Centers for Disease Control and Prevention (CDC) Guide-Breastfeeding Resource Library Link: https://www.cdc.gov/breastfeeding/ |
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Resource Title: The United States Breastfeeding Committee toolkit Link: https://www.usbreastfeeding.org/publications.html |
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Resource Title: The United States Breastfeeding Committee toolkit Link: https://www.usbreastfeeding.org/publications.html |
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Resource Title: The California Maternal Quality Care Collaborative (CMQCC) QI Toolkits Link: https://cpqcc.org/resource-categories/qi-toolkits?page=1 |
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Resource Title: The California Maternal Quality Care Collaborative (CMQCC) QI Toolkits Link: https://cpqcc.org/resource-categories/qi-toolkits?page=1 |
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Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks |
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Resource Title: Institute for Healthcare Improvement’s Better Maternal Health Outcomes Link: https://www.ihi.org/resources/tools/better-maternal-outcomes-quality-improvement-workbooks |
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Resource Title: American Hospital Association Maternal and Child Health Tools and Resources Link: https://www.aha.org/maternal-child-health-tools-resources |
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Resource Title: American Hospital Association Maternal and Child Health Tools and Resources Link: https://www.aha.org/maternal-child-health-tools-resources |
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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 |
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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 |
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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: 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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