The Joint Commission releases new measures for hip and knee replacement operations

The Joint Commission has released four new performance measures for advanced certification in total total hip and knee replacement (THKR), which is offered to accredited hospitals, critical access hospitals, and ambulatory surgery centers (ASCs). These measures—which cover the whole patient care spectrum—will be of interest to orthopaedic surgeons, as the measures target areas related to the entire perioperative period.

The four THKR measures are as follows:

  • THKR-1, regional anesthesia
  • THKR-2, postoperative ambulation on the day of surgery
  • THKR-3, discharged to home
  • THKR-4, preoperative functional/health status assessment

The process

A technical advisory panel (TAP) composed of experts in orthopaedic surgery, anesthesia, rehabilitative medicine, internal medicine, physical therapy, perioperative nursing, social work, and joint program administration collaborated to develop these performance measures. When forming the TAP, The Joint Commission sought out experts recommended by their respective medical societies and professional associations, including the American Academy of Orthopaedic Surgeons (AAOS) and the Association of periOperative Registered Nurses.

The TAP developed draft measures that were published for public comment and evaluated the feedback before making the appropriate changes. Aspects of care appropriate for performance measure development were identified through a literature search and a review of clinical practice guidelines.

The measures were then pilot tested. Data were collected at 16 hospitals and two ASCs over a six-month period. Reliability testing was completed by Joint Commission staff at six of the organizations.

The measures

Starting January 1, 2018, all THKR-certified programs and programs seeking certification must collect monthly data on these performance measures and report the data quarterly via the certification measure information process section on The Joint Commission Connect secure extranet site.

THKR-1, regional anesthesia, evaluates whether the patient received neuraxial or other forms of regional anesthesia. Regional anesthesia is associated with fewer postoperative complications and deaths than general anesthesia. Research shows that patients who received neuraxial anesthesia had statistically significant fewer 30-day mortality and in-hospital complications, including pneumonia, kidney failure, and the need for mechanical ventilation, than patients who did not receive neuraxial anesthesia.1 Additional studies show a decrease in operative blood loss and the need for blood transfusions.2-3 The AAOS clinical practice guidelines relating to management of osteoarthritis of the hip and knee state that in comparison with general anesthesia, neuraxial anesthesia can be used to improve select perioperative outcomes and complication rates.4-5

THKR-2, postoperative ambulation on the day of surgery, is strongly supported in the literature. Early ambulation as close to the time of operation as possible can reduce the risk of complications associated with bed rest, such as deep vein thrombosis, pulmonary embolism, atelectasis, pneumonia, and urinary retention. Additionally, early ambulation results in decreased length of stay and lower patient risk for hospital-acquired infections and other complications. Early ambulation leads to improvement in outcomes (range of motion, gait, balance, muscle strength, and pain) without an increase in adverse events.6

THKR-3, discharged to home, is based on the concept that home-based rehabilitation has been proven to result in better pain and functional outcomes, as well as increased patient satisfaction, than inpatient rehabilitation. This measure evaluates the percentage of patients who are discharged to home.7

Lastly, THKR-4 evaluates whether a general health and functional status patient-reported outcome (PRO) tool was completed preoperatively. Good orthopaedic care requires knowledge of the patient’s history of musculoskeletal pain and associated limitations in daily function. Integrating PRO data into routine orthopaedic patient visits can provide key information to monitor changes in symptom severity over time, support shared clinical decision making, and assess treatment effectiveness.8

In acknowledgement of the administrative burden associated with PRO data capture, The Joint Commission will implement PRO measures in a phased approach. During this first phase, the process of collecting preoperative data will be measured. During the second phase, pre- and postoperative data will be evaluated with the goal of calculating patients’ improvement scores.

While at present these measures are in a chart-based manual data collection format, The Joint Commission is testing electronic clinical quality measures for this measure set. For more information about the THKR certification program, visit the Joint Commission website.

Questions about the performance measures may be directed to Marilyn Parenzan, associate project director, department of quality measurement, The Joint Commission, at


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.


  1. Memtsoudis SG, Sun X, Chiu YL, et al. Perioperative comparative effectiveness of anesthetic technique in orthopaedic patients. Anesthesiology. 2013;118(5):1046-1058.
  2. Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for elective total hip replacement: A meta-analysis. Anesth Analg. 2006;103(4):1018-1025.
  3. Hu S, Zhang ZY, Hua YQ, Li J, Cai ZD. A comparison of regional and general anaesthesia for total replacement of the hip or knee: A meta-analysis. J Bone Joint Surg Br. 2009;91(7):935-942.
  4. McGrory BJ, Weber KL, Jevsevar DS, Sevarino K. Surgical management of osteoarthritis of the knee: Evidence-based guideline. J Am Acad Orthop Surg. 2016;24(8):e87-93.
  5. American Academy of Orthopaedic Surgeons. Management of osteoarthritis of the hip: Evidence-based clinical practice guideline. March 2017. Available at: Accessed July 27, 2017.
  6. Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: A systematic review. Clin Rehabil. 2015;29(9):844-854.
  7. Mahomed NN, Davis AM, Hawker G, et al. Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: A randomized controlled trial. J Bone Joint Surg Am. 2008;90(8):1673-1680.
  8. Ayers DC, Zheng H, Franklin PD. Integrating patient-reported outcomes into orthopaedic clinical practice: Proof of concept from FORCE-TJR. Clinical Orthop Relat Res. 2013;471(11):3419-3425.

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