The Centers for Medicare and Medicaid Services (CMS) and The Joint Commission work together to establish core quality measures that hospitals must report on. In 2003, they aligned their measures to reduce duplication of reporting efforts. Some key measures they both require relate to timely treatment of acute myocardial infarction (AMI) patients, such as administering aspirin or beta blockers within certain timeframes. Compliance with these evidence-based quality measures impacts accreditation and reimbursement.

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Acute Myocardial Infarction Measures:
CMS &The Joint Commission
Danielle Tate
MMHA 6250 Walden University

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Centers for Medicare and Medicare Services and The Joint Commission
The Centers for Medicare and Medicaid Services (CMS) is a federal agency under
the Department of Health and Human Services (HHS) that was created by the United
States Congress in 1965 to assist the elderly and those with low income. Its role has
expanded over the years and it has influenced hundreds of provisions to important laws,
like the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, The
Balanced Budget Act of 1997, and the Tax Equity and Fiscal Responsibility Act of 1982
(Iglehart, 2001). CMS has created sectors and initiatives like the Quality Improvement
Organization (QIO) and affiliates with other regulatory agencies like The Joint
Commission, the American Medical Association etc. It is geared towards quality
improvement and making recommendations for standards and guidelines for process of
care from evidenced based data and making payment decisions based on measuring data
against these recommendations (Varkey, 2010, p. 169-170). CMS focuses on patient-
centered care, healthcare organization accountability, and high quality of care and
publicly reports core measures information and quality outcome information from
hospitals and analyzes it for trends and variations and creates performance reports for
comparison (Centers for Medicare & Medicaid Services [CMS], 2015).
The Joint Commission is a not-for-profit organization that was founded in 1951. It
is the most prominent organization with regards to evaluating, accrediting, and certifying
healthcare organizations. It is independent but a Board of Commissioners oversees it.
This board contains 32 board members, made up of healthcare providers, healthcare
workers, field experts, educators, and patient advocates. Its mission is to create and
uphold high standards of quality of care and patient safety. The Joint Commission has set

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the benchmark and revolutionized safety and quality guidelines and continues to pioneer
in operational improvement (The Joint Commission, 2015a). The Joint Commission
offers a high quality, well known, and trusted seal of approval that patients consumers
can look for as a sign that an organization meets the minimum requirements of
meaningful performance standards.
Core Measures
In 2003 CMS and The Joint Commission completely aligned regarding common
core measures of care. “This resulted in the creation of one common set of measure
specifications documentation known as the Specifications Manual for National Hospital
Inpatient Quality Measured to be used by both organizations…The goal is to minimize
data collection efforts for these common measures and focus efforts on the use of data to
improve the health care delivery process” (The Joint Commission, 2016b). Due to this, an
organization would not need to choose between CMS or The Joint Commission
measures. The agreed upon standards set forth by CMS and The Joint Commission
include timely care measures, effective care measures, complications measures,
readmissions measures, medical imaging measures, and mortality measures etc. (CMS,
2016a). The core measures focus on structural measures, Hospital Consumer Assessment
of Healthcare Providers and Systems Survey (HCAHPS), timely and effective care
regarding Acute Myocardial Infarctions (AMI), timely and effective care regarding Heart
Failure (HF), timely and effective regarding Pneumonia (PN), timely and effective care
regarding the Surgical Care Improvement Projects (SCIP), timely and effective care
regarding throughput in Emergency Departments (ED), timely and effective care
regarding preventive care for the flu, timely and effective care for Children’s Asthma

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Care (CAC), timely and effective care for Strokes, timely and effective care for blood
clot prevention and treatment, timely and effective care for pregnancy and delivery,
surgical complications, complications associated with healthcare-associated infections
(HAI), 30 day rates of readmissions, 30 day rates of deaths, outpatient medical imaging
efficiency, and payment and value of care (CMS, 2016b). These measures ensure timely,
efficient, ad quality care is provided to patients.
One area of focus in the core measures is timeliness and effectiveness of care for
AMI patients. “In May 2001, the Joint Commission announced four initial core
measurement areas for hospitals, which included acute myocardial infarction (AMI) and
heart failure (HF). Simultaneously, The Joint Commission worked with the Centers for
Medicare & Medicaid Services (CMS) on the AMI, and HF sets that were common to
both organizations. CMS and the Joint Commission worked to align the measure
specifications for use in the 7th Scope of Work and for Joint Commission accredited
hospitals. Hospitals began collecting AMI measures for patient discharges beginning July
1, 2002” (The Joint Commission, 2016b). These measures state that patients should
receive aspirin within 24 hours of arrival to the hospital, aspirin should be prescribed at
discharge, ACE-Inhibitors should be prescribed for patients with left ventricular systolic
dysfunction, counseling on smoking cessation should be done, a beta blocker should be
administered within 24 hours of arrival at the hospital, a beta blocker should be
prescribed at discharge, a thrombolytic should be administered within 30 minutes of
arrival, primary percutaneous coronary intervention (PCI) should be done within 90
minutes of arrival, statin should be prescribed at discharge, and readmission and mortality
rates should be recorded in the following 30 days (CMS, 2016b). These same measures

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for AMIs are listed by The Joint Commission (The Joint Commission, 2016c). These
measures hold providers and organizations accountable and help save lives within a
critical timeframe and ensure treatments are given soon after arrival and are continued
during the period of recovery.
Relationships Between Aspects of Healthcare Quality and Safety
Quality and safety standards are created from evidenced based data that has been
collected, analyzed, verified, and agreed upon by CMS, The Joint Commission, and other
healthcare entities (Varkey, 2010). “The Core Quality Measure Collaborative, led by the
America’s Health Insurance Plans (AHIP) and its member plans’ Chief Medical Officers,
leaders from CMS and the National Quality Forum (NQF), as well as national physician
organizations, employers and consumers, worked hard to reach consensus on core
performance measures. Through the use of a multi-stakeholder process, the Collaborative
promotes alignment and harmonization of measure use and collection across payers in
both the public and private sectors ” (CMS, 2016c). Trends in standards often become
performance measures that are used in the accreditation, certification, credentialing, and
payment reimbursement processes. When changes are made healthcare organizations
receive updated manuals, websites, training, and educational materials from CMS, The
Joint Commission, and other entities (The Joint Commission, 2016d). Now that CMS has
aligned with The Joint Commission and other entities, each step in this process is related
and connected and they influence each other.
Although these measures are created and agreed upon by experts in this field,
some suggest alternative to consider. In a study done by Schull, Vermeulen, Donovan,
Newman, and Tu (2005), it was suggested that instead of using the current benchmark of

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administering reperfusions to AMI patients within the specific timeframes discussed
above, that organizations use a performance measure based on door-to-needle time
(DNT) at less than 30 minutes. The measures are limited by the quality of data provided.
“It is difficult to have actionable and useful information because physicians and other
clinicians must currently report multiple quality measures to different entities. Measure
requirements are often not aligned among payers, which has resulted in confusion and
complexity for reporting providers” (CMS, 2016c). Some states do not require reporting
of certain data. Negative outcomes and mistakes are not always reported for fear of being
reprimanded and/or being fined (Halpin, Milstein, Shortell, Vanneman, & Rosenberg,
2011).
Resources
Centers for Medicare & Medicaid Services [CMS]. (2015, September 29). Outcome
measures. Retrieved from the CMS website: https://www.cms.gov/medicare/quality-
initiatives-patient-assessment-instruments/hospitalqualityinits/outcomemeasures.html
Centers for Medicare & Medicaid Services [CMS]. (2016c, February 16). Core measures.
Retrieved from the CMS website: https://www.cms.gov/Medicare/Quality-Initiatives-
Patient-Assessment-Instruments/QualityMeasures/Core-Measures.html
Centers for Medicare & Medicaid Services [CMS]. (2016a, May 14). Timely & effective
care measures. Retrieved from the CMS website:
https://www.medicare.gov/hospitalcompare/Data/Measures.html

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Centers for Medicare & Medicaid Services [CMS]. (2016b, May 14). Measures and
current data collection periods. Retrieved from the CMS website:
https://www.medicare.gov/hospitalcompare/Data/Data-Updated.html#
Halpin, H., Milstein, A., Shortell, S., Vanneman, M., & Rosenberg, J. (2011), Mandatory
public reporting of hospital-acquired infection rates: a report from California. Health
Affairs, 30 (4), 723-729. Retrieved from: https://search-proquest-
com.ezp.waldenulibrary.org/pqcentral/docview/864025897/C379EE5CC7AF4201PQ/5?a
ccountid=14872
Iglehart, J. (2001). The Centers for Medicare and Medicaid Services. The New England
Journal of Medicine, 345 (26), 1920-1924. Retrieved from: https://search-proquest-
com.ezp.waldenulibrary.org/pqcentral/docview/223942215/B5E066FA031841D8PQ/4?a
ccountid=14872
Schull, M., Vermeulen, M., Donovan, L., Newman, A., & Tu, J. (2005). Can the wrong
statistic be bad for health? Improving the reporting of door-to-needle time performance in
acute myocardial infarction. The American Heart Journal, 150 (3), 583-587. Retrieved
from: https://search-proquest-
com.ezp.waldenulibrary.org/pqcentral/docview/1504621660/DFD6FAB1D8B347D6PQ/
6?accountid=14872

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The Joint Commission. (2015a, July 29). Facts about The Joint Commission. Retrieved
from The Joint Commission website:
https://www.jointcommission.org/facts_about_the_joint_commission/
The Joint Commission. (2016a, February 23). Facts about quality check and quality
reports. Retrieved from The Joint Commission website:
https://www.jointcommission.org/facts_about_quality_check_and_quality_reports/
The Joint Commission. (2016d, March 25). Facts about Joint Commission standards.
Retrieved from The Joint Commission website:
https://www.jointcommission.org/facts_about_joint_commission_accreditation_standards
/
The Joint Commission. (2016b, May 14). Core measure sets. Retrieved from The Joint
Commission website: https://www.jointcommission.org/core_measure_sets.aspx
The Joint Commission. (2016c, May 14). Acute Myocardial Infarction core measure set.
Retrieved from The Joint Commission website:
http://www.jointcommission.org/assets/1/6/Acute%20Myocardial%20Infarction.pdf
Varkey, P. (2010). Medical quality management: Theory and practice. Sudbury,
MA: Jones & Bartlett.