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Public Comment on Draft eCQMs for Advanced Certification in Total Hip and Total Knee Replacements (THKR)

March 6, 2018 - 6:37am

The Joint Commission (TJC) introduced an advanced certification program for Total Hip and Total Knee Replacements (THKR) in 2016. This voluntary certification program for accredited organizations supports quality, consistency, and safety throughout the pre-operative, intra-operative, and post-operative phases of care. The program applies to surgeries performed in the inpatient, hospital-based outpatient, and ambulatory surgery settings.  A set of performance measures was developed to enhance the Advanced Certification of THKR program. These measures provide comparative data to certified programs to assist in the evaluation of key processes and outcomes for purposes of performance improvement. These measures are chart-based (require manual data abstracted) and are required for all certified organizations effective 1/1/2018.

The Joint Commission has developed draft inpatient electronic clinical quality measuresinfo-icon (eCQMsinfo-icon) as a reporting option for inpatient facilities who achieve advanced certification in THKR. These draft eCQMs are based on Quality Data Model (QDM)info-icon Version 4.3 and do not contain Clinical Quality Language (CQL)info-icon at this time. As part of the measure development process, we are soliciting feedback about the importance, scientific acceptability, usability, feasibility, and logic construct during a public comment periodinfo-icon which is open now and runs through April 6, 2018. Following the public comment period, the survey results will be reviewed by the eCQMinfo-icon Task Force and used to further refine the measure specificationsinfo-icon.

Additionally, TJC is seeking hospitals to volunteer as pilot sites to evaluate these eCQMs via a workflow and feasibility assessment, trial chart abstraction and electronic data submission during an on-site visit with TJC staff members. These visits are intended as an opportunity for the volunteer hospital to provide feedback and ask questions about the eCQMs, and for The Joint Commission to obtain valuable insight from the hospital.

Participation in this testing will not, in any way, affect the accreditation/certification process nor impact any participating organization's Joint Commission accreditation/certification status.

If you are interested in volunteering as a pilot site, there is a space to indicate such on the survey tool. You will be contacted after the public comment period closes on April 6th to help us determine which hospitals will be chosen for participation.

Feedback is welcome on these eCQMS during the public comment period which is open now through April 6, 2018.  Please complete the survey tool which can be found at the following link: 

Please direct any questions to Marilyn Parenzan, Associate Project Director at  Thank you in advance for your participation. 

Last Updated: March 6, 2018