Joint Commission Certifications

The Joint Commission Certifications: What’s New and What’s Newer

Certifications – Disease Specific

The Joint Commission has had certifications available across the full spectrum of Orthopedic conditions for some time, but as most of you know, they have also added Advanced Certifications for procedures for several patient populations. Patient-Reported Outcome Measures (PROMs) and Patient-Reported Experience Measures (PREMs) are both important components of Joint Commission – Disease Specific Certification Programs (JC-DSC). Certifications were developed in collaboration with the American Academy of Orthopaedic Surgeons (AAOS) with the goal of addressing and improving:

• Program Structure
• Delivery of Care
• Care Coordination
• Performance Measurement

These JC-DSC programs include certification in the following Orthopedic conditions:

• Spine Injury
• Spine Surgery

These plans require documentation of performance measure data decisions, discussions, meetings and development of program measures. During review and on-site visits to certify the program, this documentation is critical and requires complete transparency of the process.

Advanced Certifications

JC-DSC also includes Advanced Certification for Total Hip and Total Knee Replacement and (starting July 1st) Spine Surgery. Each program includes expectations of written performance improvement plans.

Within the written performance improvement plan, requirements include:

• Performance Measure Data
• Collected and reported

Four measures are required:

1. Continuous Quality Improvement Reports
2. Performance Improvement Action Planning
3. Meeting notes, agenda
4. How data is analyzed and utilized

How Disease Specific and Advanced Certifications Differ

Advanced certification goes beyond the core certification of the basic JC-DSC to include:

• Prescriptive Approach: Advanced certification standards offer relevant, prescriptive approach over the generalized guidelines
• Relevant Metrics: standards and performance measures are specific to Total Joint and/or Spine Surgery while allowing flexibility in clinical practice guidelines
• Expanded Scope: Advanced certification encompasses the entire continuum of care
• Professional Collaboration: offered in collaboration with AAOS

Advanced Knee and Hip Replacement programs additional requirements include:

Membership and reporting in AAOS’ American Joint Replacement Registry

Inclusion of four (4) specific metrics beyond the four (4) collected as part of performance improvement plan –

• Infection rate
• Bleeding and blood loss
• Venous Thrombosis
• Readmission Rate

What’s New to Advanced Certifications

Data collection for a new standardized performance measure assessing a patient’s functional and health status post-operatively will be required for the Advanced Certification for Total Hip and Total Knee Replacement (THKR). The change here is that it is no longer just pre-operative outcomes required, but also post-operative outcomes. The standardized measures listed by The Joint Commission are:

• Regional Anesthesia
• Post-operative Ambulation on Day of Surgery
• Discharge to Home
• Pre-operative Functional/Health Status Assessment (Patient Reported Outcomes)
• Post-operative Functional/Health Status Assessment – (Patient Reported Outcomes) New Measure

If you’re already a certified THKR organization, this is good news for you! Keep doing what you’re doing, just add the post-op assessment. If you’re looking to get that certification, these measures will be required beginning with discharges on or after July 1, 2021.

More detailed information on THKR inpatient and outpatient measure specifications can be found in Specification Manual for Joint Commission National Quality Measures.

What you need to know about the Advanced Spine Surgery Certification

• Program has served a minimum of 200 patients
• Use of standardized clinical care delivery based on evidence-based care and clinical practice guidelines
• Data collection and performance measurement data, due beginning July 1, 2021.
• Participates in the American Spine Registry which is a collaborative effort of the American Association of the Neurological Surgeons (AANS) and (AAOS)

Joint Commission-certified programs and organizations seeking initial certification are required to adopt a set of standardized performance measures. Organizations collect monthly data for each measure in the set. The data is then submitted quarterly to The Joint Commission.

These specific Spine Surgery measures are

• Surgical Site Infection Rates
• New Neurological Deficits
• Unplanned Return Visit to the OR
• PROMs

Am I Too Late?

Not at all! CODE’s average “go-live” timeline is thirty (30) days from the kickoff call and we maintain an average of 80% survey completion rate up to 1-year postoperative for elective orthopedic procedures. If you are looking to get your certification as soon as possible, CODE can manage that for you while collecting all the data you need. The best part, CODE’s PRO-trained account managers make sure it is little to no extra work for you and your team.

CODE Can Help

CODE is ready to assist and partner with health care organizations to qualify and gain JC-DSC or Advanced Certifications in Total Hip and Knee Replacements and Spine Surgery through collecting and reporting on standardized performance measures. Taking this requirement out of the clinic permits physicians and teams to concentrate on patient care and throughput, while CODE takes on the administrative burden of PROMs and PREMs collection, analysis and reporting.

At CODE, we love outcomes. Our world revolves around improving the quality of patient care and improving quality of life. CODE’s specialty is collecting PROs, benchmarking them with all the top registries (including but not limited to AAOS) then making reporting a breeze. Our clients know how much insight into a patient’s experience that data can provide, and it is always great to see them incorporated into new initiatives across the healthcare community. If you are looking to start your PROs program in order to achieve Advanced Certification, or if you are already collecting PROs and would like some advice about how to be more effective, we would love to talk!