JCAHO - CMS Core Measures Dashboard in Excel


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JCAHO - CMS Core Measures

Need a better way to report your JCAHO Core Measures to your leadership team? Does your monthly reporting process take too much time?

With our new JCAHO - CMS Core Measures dashboard in Excel, just input your data directly into the pre-formatted data entry sheet and color coded scorecards and a dashboard of control charts are automatically created.

This system consists of four parts:

  1. A pre-populated spreadsheet listing all measures and their definitions. This sheet can be updated to meet your needs.
  2. A data input sheet to record your results.
  3. A color-coded (green, yellow, red -- good, poor, bad) scorecard that shows how well you're performing against targets.
  4. A control chart for each measurement that shows actual performance as a graph.

Here are examples of each sheet:

Core Measures Definitions Sheet

JCAHO definition sheet

Core Measures Data Input Sheet

Just input your data into the yellow shaded cells.

JCAHO data input sheet

Color Coded Scorecard showing your results against targets.

Automatically populates from your data entry sheet. Also, contains a column to the left for data analysis notes and action plans.

JCAHO color coded scorecard

Dashboard of Control Charts

Automatically creates control charts for each of your measures.

JCAHO control chart dashboard

Core Measures included in the JCAHO - CMS Core Measures dashboard include:

Acute Myocardial Infarction (AMI)

  • AMI-1 Aspirin at Arrival
  • AMI-2 Aspirin Prescribed at Discharge
  • AMI-3 ACEI or ARB for LVSD
  • AMI-4 Adult Smoking Cessation Advice/Counseling
  • AMI-5 Beta Blocker Prescribed at Discharge
  • AMI-6 Beta Blocker at Arrival
  • AMI-7 Median Time to Thrombolysis
  • AMI-7a Thrombolytic Agent Received Within 30 Minutes of Hospital Arrival
  • AMI-8 Median Time to PTCA
  • AMI-8a PCI received within 120 minutes of hospital arrival
  • AMI-9 JCAHO Only Inpatient mortality

Heart Failure (HF)

  • HF-1 Discharge Instructions
  • HF-2 LVF Assessment
  • HF-3 ACEI or ARB for LVSD
  • HF-4 Adult Smoking Cessation Advice/Counseling

Pneumonia (PN)

  • PN-1 Oxygenation assessment
  • PN-2 Pneumococcal screening and/or vaccination
  • PN-3a Blood Cultures for ICU
  • PN-3b Blood Culture Before First Antibiotic
  • PN-4 Adult smoking cessation advice/counseling
  • PN-5 Antibiotic timing
  • PN-5a Initial antibiotic received within 8 hours of hospital arrival
  • PN-5b Initial antibiotic received within 4 hours of hospital arrival
  • PN-6 Immunocompetent patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours.
  • PN-6a Immunocompetent ICU patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours.
  • PN-6b Immunocompetent non-Intensive Care Unit (ICU) patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours.
  • PN-7 Influenza vaccination

Pregnancy and related conditions (PRC)

  • PRC-1 VBAC
  • PRC-2 Neonatal Mortality
  • PRC-3 Third or Fourth Degree Laceration

Surgical Infection Prevention (SIP)

  • SIP-1 Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision
  • SIP-2 Prophylactic Antibiotic Selection for Surgical Patients
  • SIP-3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time


JCAHO - CMS Core Measures Dashboard

Only $2,497 per hospital. Item #930.
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