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PREVIOUS ACTIONS & ALERTS - 2009

Joint Commission releases specifications for perinatal core measures

In late 2007, The Joint Commission’s Board of Commissioners recommended retiring and replacing the Pregnancy and Related Conditions (PR) measure set with an expanded set of evidenced-based measures. A technical advisory panel (TAP) comprising experts in the perinatal care field was convened in February 2009 to select the replacement set of measures from among those endorsed for national use by the National Quality Forum. This expanded measure set, now referred to as Perinatal Care (PC) comprises the following measures.

  • Elective deliveries
  • Cesarean sections
  • Antenatal steroids
  • Health care–associated bloodstream infections in newborns
  • Exclusive breast milk feeding

The Joint Commission's core measures serve as a national, standardized performance measurement system providing assessments of care delivered in given focus areas. One factor causing varying compliance with core measures may be a lack of awareness of the evidence connecting processes of care to improved outcomes. Even though they are collecting data, many hospitals continue to struggle with how to make that data useful. Core Measures should be used to achieve noticeable performance improvements at your facility. The data gathered should be applied, rather than letting your efforts go to waste once the data are reported. Clinicians should plan a course of action to turn those results into actionable changes and implement those changes to create quality improvements. Hospitals across the country are measured and compared by The Joint Commission against all other accredited institutions on their performance in these Core Measures. This way, consumers can compare their hospital against national data.

The Joint Commission has just posted the Perinatal Core Measure specifications that include exclusive breastmilk feeding upon discharge. You can see it at http://manual.jointcommission.org/releases/TJC2010A/PerinatalCare.html. You may wish to inform your hospital that this measure set and specifications are available and urge that the hospital choose it as a core measure to be addressed. The Joint Commission requires hospitals to choose a minimum of 4 out of the 11 core measure sets, thus hospitals are not required to choose the perinatal core measure that includes exclusive breastmilk feeding upon discharge. It may be a wise idea to check and see if your hospital will be addressing this measure. If you have an opportunity to influence the choice, now is the time. Find out who is responsible for overseeing the Joint Commission assessment process and if the perinatal core measure will be included in the next round of assessments. This is an opportune time to share the evidence regarding the importance of exclusive breastmilk feeding and to keep the concept of improved lactation care and services on the radar of administration. You could also add that your hospital’s mPINC score was perhaps not as good as it should have been and that choosing the perinatal core measure set would help improve the score in the next mPINC survey.

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FORMULA RECALLS

RESOURCES

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