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America’s Hospitals: Improving Quality and Safety
Annual Report
2017
TABLE OF CONTENTS
Leaders’ Letter 3
Executive Summary 4
Graph 1: Percent of hospitals with overall accountability composite greater than 95 percent 6
Pioneers in Quality™ 7
List 1: 2017 Pioneers in Quality™ Expert and Solution Contributors 8
eCQM Data Summary 9
Table 1: Number of eCQM sets submitted for 2016 10
Graph 2: Most frequently reported eCQMs for 2016 10
Table 2: Summary of values for eCQMs reported in 2016 11
List 2: 2016 electronic clinical quality measures (eCQMs) 12
Accountability Measures Summary 13
Table 3: Measure set composite results for accountability measures 13
Table 4: Percentage of hospitals achieving composite rates greater than 95 percent
for accountability measure sets 13
List 3: 2016 accountability measures 14
National Performance Summary 15
Table 5: Inpatient psychiatric services measure results 15
Table 6: Inpatient psychiatric services rate measure results 16
Table 7: Venous thromboembolism (VTE) care measure results 18
Table 8: Stroke care measure results 18
Table 9: Perinatal care measure results 19
Table 10: Immunization measure results 19
Table 11: Tobacco use treatment measure results 19
Table 12: Substance use care measure results 20
Table 13: Percentage of hospitals achieving 95 percent or greater performance 20
State Maps 21
State Maps 1: Inpatient psychiatric services measures 21
State Maps 2: Venous thromboembolism (VTE) care measures 22
State Maps 3: Stroke care measures 22
State Maps 4: Perinatal care measures 23
State Maps 5: Immunization measure 24
State Maps 6: Tobacco use treatment measures 24
State Maps 7: Substance use care measures 26
Understanding the Quality of Care Measures 28
Glossary 32
Mark R. Chassin, MD
David W. Baker, MD
LEADERS’ LETTER
The last year has been a time of tremendous
change and many challenges in quality
measurement with the expansion of
requirements for electronic clinical quality
measure (eCQM) reporting. The Joint
Commission believes that care processes
and patient outcomes can be improved and
sustained only through the gathering and
analysis of performance data and by an
organized and comprehensive approach to
performance improvement. In 2016, The
Joint Commission created the Pioneers in
Quality™ program to assist hospitals in their
adoption of eCQMs. This year, we begin our
report, America’s Hospitals: Improving Quality
and Safety – The Joint Commission’s Annual
Report 2017, by recognizing the first hospitals
that have successfully leveraged eCQMs and
health IT to drive quality improvement.
Joint Commission-accredited hospitals could
select and report performance data on 23
different eCQMs in eight measure sets during
2016, and we aligned these requirements as
closely as possible to those for the Centers
for Medicare & Medicaid Services (CMS)
Hospital Inpatient Quality Reporting
Program. This year, 470 Pioneers in Quality™
Data Contributors voluntarily provided
2016 eCQM data to The Joint Commission.
Of these hospitals, 11 were named Solution
Contributors by submitting a proven practice
to The Joint Commission’s Proven Practices
Collection, and nine achieved the status
of Expert Contributors by advancing the
evolution and use of eCQMs.
Hospitals have gained increased confidence
in reporting eCQM data, thanks in part to
the assistance provided by the Pioneers in
Quality™ program, and most plan to report
these data in 2017, according to surveys
conducted by The Joint Commission.
Meanwhile, Joint Commission-accredited
hospitals continue to make strides in
performance on our traditional core quality
measures. Since 2002, when The Joint
Commission began following performance
on core quality measures, improvements
have been tracked and the bar raised each
year. Accountability measures are evidence-
based care processes closely associated
with positive patient outcomes. A total of
14 core measures were retired by CMS and
The Joint Commission at the end of 2015
because performance was consistently very
high; this year’s report documents 2016
performance on the remaining 15 different
chart-abstracted accountability measures in
seven measure sets.
The data summarized in this report
represents 17.3 million opportunities to
provide evidence-based patient care, and
performance continues to be outstanding.
Because of the close link between these
measures and patient outcomes, we can be
confident that these measures are helping
to drive quality improvement and lower
patient morbidity and mortality.
Sincerely,
Mark R. Chassin, MD, FACP, MPP, MPH
President and Chief Executive Officer
The Joint Commission
David W. Baker, MD, MPH, FACP
Executive Vice President
Division of Health Care Quality Evaluation
The Joint Commission
3
EXECUTIVE SUMMARY
The last year has been a time of tremendous change
and many challenges in quality measurement with
the expansion of requirements for electronic clinical
quality measure (eCQM) reporting. In 2016, The Joint
Commission created the Pioneers in Quality™ program to
assist hospitals in their adoption of eCQMs. Therefore, we
begin our report, America’s Hospitals: Improving Quality
and Safety – The Joint Commission’s Annual Report 2017,
by discussing eCQM reporting to The Joint Commission
and recognizing the first hospitals that have successfully
leveraged eCQMs and health IT to drive quality
improvement.
Joint Commission-accredited hospitals could select
and report performance data on 23 different eCQMs in
eight measure sets during 2016, and we aligned these
requirements as closely as possible to those for the Centers
for Medicare & Medicaid Services (CMS) Hospital Inpatient
Quality Reporting Program.
The report then discusses performance on our traditional
core quality measures. A total of 14 core measures were
retired by CMS and The Joint Commission at the end of
2015 because performance was consistently very high;
this year’s report documents 2016 performance on the
remaining 15 different chart-abstracted accountability
measures in seven measure sets.
This year’s report
shows hospitals’
continued strong
performance on
these measures.
While the data
show impressive
gains in
hospital quality,
improvements can
still be made. Some
hospitals perform better than others in treating particular
conditions. More than 3,200 Joint Commission-accredited
hospitals contributed data. Quality and safety results for
specific hospitals can be found at www.qualitycheck.org.
The key findings of the report are:
1. 470 hospitals reported eCQM data in 2016. This represents a dramatic increase from the 34 hospitals
that voluntarily submitted eCQM data in 2015. In 2017, we
expect that the number of reporting hospitals will increase
to more than 2,000. We recognize:
• 470 Data Contributors: Hospitals that voluntarily
transmitted eCQM data for The Joint Commission’s
production database.
• Nine Expert Contributors: Hospitals that advanced the
evolution and utilization of eCQMs through
contributions, by presenting at a Pioneers in Quality™
webinar or participating in eCQM development.
• 11 Solution Contributors: Hospitals that submitted
a Proven Practice selected for inclusion in The Joint
Commission’s Proven Practices Collection. Introduced
in April, the Proven Practices Collection is a new
resource available to Joint Commission-accredited
hospitals. This new initiative recognizes hospitals that
have successfully leveraged eCQMs and health IT to
drive quality improvement.
The success stories of the Expert and Solution Contributors
are shared via the Pioneers in Quality™ webinars, which
assists hospitals on their journey toward eCQM adoption.
4
2. Two voice of the customer surveys on eCQMs conducted by The Joint Commission found that awareness of eCQM reporting requirements is very high and most hospitals plan to report 2017 eCQM data to CMS. Compared to hospitals responding to the first survey
conducted in spring 2016, hospitals participating in the
second survey in fall 2016 revealed:
• More willingness to report voluntarily
• More confidence about the accuracy of their eCQM data
• Increased perceived readiness to successfully submit
eCQM data
• Increased confidence in generating quality reporting
document architecture (QRDA) Category 1 documents
• The ability to submit using their own electronic health
records (EHR) data
3. Hospital performance on accountability measures continued to be strong, greatly enhancing the quality of care provided in Joint Commission-accredited hospitals. Accountability measures are evidence-based care
processes closely associated with positive patient
outcomes. The 2016 overall accountability composite
calculation is derived from a total of 15 accountability
measures from seven sets (inpatient psychiatric services,
venous thromboembolism (VTE) care, stroke care,
perinatal care, immunization, tobacco use treatment, and
substance use care).
In 2016, improvements on several individual measures
increased as much as 9.8 percentage points. Performance
on a few individual measures declined slightly. Relatively
small percentage-point improvements on measures for
which performance is already strong can often require as
much or even more diligence than large percentage-point
improvements where much room for improvement exists.
All improvements are important and contribute to better
care for patients.
• The 2016 inpatient psychiatric services result is 92.1
percent, up from 89.7 percent in 2012 – an improvement
of 2.4 percentage points.
• The 2016 perinatal care result is 98.1 percent, up from
57.6 percent in 2012 – an improvement of 40.5
percentage points.
• The 2016 tobacco use treatment result is 87.7 percent,
up from 75.8 percent in 2014 – an improvement of 11.9
percentage points.
• The 2016 substance use care result is 82.2 percent,
up from 58.2 percent in 2014 – an improvement of 24.0
percentage points.
The heart attack and
children’s asthma care
accountability measures
included in last year’s
report have been retired.
There are no VTE, stroke
or immunization measure
set composites this year because a measure set composite
must have at least two measures and these measure
sets are comprised of only one accountability measure.
Performance on the individual measures on these clinical
topics showed good improvement.
• The VTE warfarin discharge instructions measure
result is 92.9 percent, up from 82.2 percent in 2012 – an
improvement of 10.7 percentage points.
• The stroke care thrombolytic therapy result is 89.6
percent, up from 77.3 percent in 2012 – an improvement
of 12.3 percentage points.
• The influenza immunization measure result is 94.3
percent, up from 86.2 percent in 2012 – an improvement
of 8.2 percentage points.
5
EXECUTIVE SUMMARY (cont.)
Performance on the above three measures was included
in the overall accountability composite results. Composite
accountability measures have been compiled for inpatient
psychiatric services, VTE and stroke care since 2011,
for perinatal care and immunization since 2012, and for
tobacco use treatment and substance use care since 2014.
The composites for each year are calculated on measures
active for the entire year; active measures can change from
year to year. For more information about accountability
composite results versus composite results, see “Note on
Calculations and Methodology.”
4. The 2016 composite accountability score declined slightly, which we believe is due to the retiring of measures that had a very high performance in the past. The Joint Commission analyzes improvement with a
“composite” result, which sums up the results of individual
accountability process measures into a single summary
score. While the composite performance increased for
all the measure sets, the overall composite decreased
slightly from 93.7 percent in 2015 to 92.4 percent in
2016. This is due to the fact that 14 measures that had
been used for many years were retired. These retired
measures contributed roughly half of all cases to the 2015
accountability composite rate. Thus, the apparent decrease
in the composite score from 2015 to 2016 is a result of
removing these measures.
6
The retirement of the measures was made to reduce
the burden of reporting on organizations and to allow
them to focus on areas where there are still significant
opportunities to improve. The report also includes
performance data on two non-accountability process
measures noted within the measure sets (VTE-6: Incidence
of potentially preventable VTE, and PC-05: Exclusive breast
milk feeding), and two outcome measures (PC-02: Cesarean
section, and PC-04: Newborn bloodstream infections).
The overall composite accountability score reflects 17.3
million opportunities to perform care processes closely
linked to positive patient outcomes. Since the baseline
has been significantly altered by the retirement of the
measures, caution should be taken when comparing the
2015 and 2016 composite scores.
Measure sets with composite performance below the
overall composite rate of 92.4 percent are inpatient
psychiatric services (92.1 percent), tobacco use treatment
(87.7 percent), and substance use care (82.2 percent). The
92.4 percent result identifies the rate at which evidence-
based core measure practice is provided – combined over
all hospitals – for every 100 opportunities to do so.
The 59.6 percent result measures the percentage of
hospitals achieving overall composite performance greater
than 95 percent.
Since implementation
in 2002, the average
number of hospitals
reporting data was
3,262 and ranged
from 3,073 to 3,419.
Graph 1: Percent of hospitals with overall accountability
composite greater than 95 percent
EXECUTIVE SUMMARY (cont.)
PIONEERS IN QUALITY™
Pioneers in Quality™ is a Joint Commission program
started in 2016 to assist hospitals on their journey toward
electronic clinical quality measure (eCQM) adoption and
reporting. Hospitals collect eCQM information through
electronic health records (EHRs) and transmit the data to
The Joint Commission (as part of its ORYX® performance
measurement requirements) and to the Centers for
Medicare & Medicaid Services (CMS).
The Pioneers in Quality™ program provided resources
to aid hospitals in the transition from chart-abstracted
measures to eCQMs. Key components of the Pioneers in
Quality™ program include:
• Regular educational webinars focused on eCQM
adoption, including continuing education units (CEUs)
for live webinar participation
• Expert-to-Expert series webinars
• A comprehensive eCQM resource portal
• The Joint Commission’s annual report, focusing on
components of the program and the evolution of
eCQM measurement
• Recognition for eCQM pioneers, including in the
annual report
• A Pioneers in Quality™ Technical Advisory Panel
• Outreach through The Joint Commission’s
Speaker’s Bureau
In 2016, 470 hospitals
chose to submit eCQM
data; those hospitals
were asked to submit
a minimum of one
quarter of data. The
470 hospitals are an
increase from the
34 hospitals that
voluntarily submitted eCQM data in 2015. In 2017, the
number of reporting hospitals is expected to increase to
more than 2,000.
Pioneers in Quality™ recognizes hospitals in three
categories:
• 470 Data Contributors: Hospitals that voluntarily
transmitted eCQM data for The Joint Commission’s
production database.
• Nine Expert Contributors: Hospitals that advanced the
evolution and utilization of eCQMs through
contributions, by presenting at a Pioneers in Quality™
webinar or participating in eCQM development.
• 11 Solution Contributors: Hospitals that submitted
a Proven Practice selected for inclusion in The Joint
Commission’s Proven Practices Collection.
See the 2017 Pioneers in Quality™ Expert and Solution
Contributors.
The Pioneers in Quality™: Proven Practices Collection is
a new resource that will be available to Joint Commission-
accredited hospitals. In spring 2017, hospitals submitted
their success stories via an online application form that
asked applicants to clearly link their accomplishments to
the use of eCQMs and health IT for quality improvement.
While this annual report shares high-level eCQM data,
The Joint Commission is not publicly reporting 2016 and
2017 eCQM data on Quality Check® because the accuracy
of eCQMs continues to be a concern. Hospitals reporting
on chart-abstracted measures will continue to have their
data and performance on the chart-abstracted measures
reported on Quality Check®.
The Joint Commission aligned our eCQM reporting
requirements as closely as possible to the CMS Hospital
Inpatient Quality Reporting Program. During 2016, there
were 23 eCQMs from which Joint Commission-accredited
hospitals could select and report performance data.
For more information on Pioneers in Quality™ or
the Proven Practices Collection, visit the Pioneers in
Quality™ web portal, which includes the 2017 eCQM Data
Contributors being recognized by The Joint Commission.
7
8
PIONEERS IN QUALITY (cont.)
List 1: 2017 Pioneers in Quality™ Expert and Solution Contributors
Hospital Expert Contributor
SolutionContributor
Pioneers in
Quality™
is a Joint
Commission
program started
in 2016 to assist
hospitals on
their journey
toward
electronic
clinical quality
measure (eCQM)
adoption and
reporting.
BayCare Health System, Inc., Clearwater, Florida
Centura Health-Penrose St. Francis Health Services, Colorado Springs, CO
Hospital Corporation of America (HCA), Nashville, Tennessee
MedStar St. Mary’s Hospital, Leonardtown, Maryland
Memorial Hermann Healthcare System, Houston, Texas
OSF Saint Elizabeth Medical Center, Ottawa, Illinois
Providence Sacred Heart Medical Center, Spokane, Washington
Rush University Medical Center, Chicago, Illinois
St. Luke’s Cornwall Hospital, Newburgh, New York
St. Mary Medical Center, Langhorne, Pennsylvania
Trinity Health, Livonia, Michigan
TriStar Centennial Medical Center, Nashville, Tennessee
University Medical Center New Orleans, New Orleans, Louisiana
UPMC, Pittsburgh, Pennsylvania
Virginia Commonwealth University Health System, Richmond, Virginia
Since 2002, hospitals have been reporting data to The
Joint Commission as a requirement of accreditation.
Through electronic clinical quality measures (eCQMs),
hospitals can electronically collect and transmit data
on the quality of care that patients receive — data that
can be analyzed to measure and improve care processes,
performances and outcomes.
Recent changes to The Joint Commission’s ORYX®
performance measurement requirements are the
result of the transition to eCQMs, as well as efforts to
maintain close alignment with the Centers for Medicare
& Medicaid Services (CMS) Hospital Inpatient Quality
Reporting Program.
Why are eCQM rates different from chart-abstracted measure rates?
Due to the differences in how eCQMs and chart-
abstracted measures are calculated, it is not surprising
that we see apparent differences in performance rates.
Performance rates on eCQM measures appear to be lower
than expected when compared to the rates of chart
review measures.
There are several reasons why eCQM rates are different
from chart-abstracted measure rates:
• Specifications for eCQMs and chart-abstracted
specifications are different: The representation of data
elements and inclusions and exclusions are constrained
by the standards used to represent eCQMs, as well as
by the information that is captured in a structured and
encoded fashion in an EHR system. For example, a
chart-abstracted data element may be represented by
multiple data elements in the eCQM.
• Data sources for eCQMs are more limited than data
sources used for chart-abstracted measures: eCQMs
rely solely on data that is captured in a structured and
encoded fashion in the EHR. In addition, eCQMs
typically rely on a single structured data field in the
EHR for a given data element. Discrepancies in rates
often happen when data is not consistently captured in
the field selected for data extraction.
• Release schedules and updates for eCQM specifications
and chart-abstracted specifications are not always
aligned: While there are continued efforts to keep
eCQMs and chart-abstracted measure specifications as
closely aligned as possible, eCQM specifications updates
are released on a different schedule than the chart-
abstracted measures manual. Updates for eCQMs are
published once a year in early spring, whereas the
chart-abstracted measures manual is released twice a
year, in January and July.
Voice of the customer survey on eCQMs
During 2016, The Joint Commission conducted two voice
of the customer surveys on eCQMs — one in the spring
and another in the fall. The surveys found that awareness
of reporting requirements is very high and for 2017 most
hospitals plan to report eCQMs to CMS, as required.
Compared to responses to
the first survey, hospitals
participating in the second
survey showed more willingness
to report voluntarily, more
confidence about the accuracy
of their eCQM data, increased
perceived readiness to
successfully submit eCQM data,
increased confidence in generating quality reporting
document architecture (QRDA) Category 1 documents, and
greater ability to submit EHR data.
9
“Align with
CMS so we are
doing the same
thing for both.”
eCQM DATA SUMMARY
Comments from accredited hospitals included requests for
more alignment with CMS to make data submission more
efficient, and that changes to workflow and
processes were necessary for eCQM reporting. Specific
comments included:
• “Align with CMS so we are doing the same thing
for both.”
• “There is a ton of work to be done to prepare for eCQMs
that include workflow changes, documentation
changes, education, and follow up on measures.”
Another customer pointed out the advantage of using
electronic methods to measure quality, so that “efforts
can be focused on improvement rather than obtaining
data.” Other customers requested support from The Joint
Commission via best practices, webinars, and other
educational offerings and resources. The Pioneers in
Quality™ program has provided this needed education.
“We have appreciated the forum to ask questions and
discuss concerns,” one commented.
See the 2016 eCQMs.
Table 1: Number of eCQM sets submitted for 2016
Graph 2: Most frequently reported eCQMs for 2016
10
eCQM DATA SUMMARY (cont.)
1 109 23.1%
2 314 66.7%
3 38 8.1%
4 5 1.1%
5 1 0.2%
6 4 0.9%
Number of eCQM sets submitted
Number of hospitals Percent
“There is a ton of work to be done to
prepare for eCQMs that include workflow
changes, documentation changes,
education, and follow up on measures.”
Mea
sure
Set
sNo. of Hospitals Reporting Measure Sets
These topic areas are in alignment with CMS eCQMs.
The top three areas (eED, eVTE and eSTK) are eCQMs that
hospitals have been reporting for the longest time.
eCQM measure No. of hospitals No. of records Average time Rate (%)
eAMI-8a: Primary PCI received within 90 minutes 1 3 100.0%
eCAC-3: Home management plan of care 4 154 91.6%
eED-1a: Median time (minutes) from ED arrival to ED departure for admitted ED patients 403 660,740 270.2
eED-2a: Admit decision time (minutes) to ED departure time for admitted patients 354 502,642 60.5
eEHDI-1a: Hearing screening prior to discharge 12 5,226 76.3%
ePC-01: Elective delivery* 43 912 43.0%
ePC-05: Exclusive breast milk feeding 16 4,558 32.7%
ePC-05a: Exclusive breast milk feeding considering mother’s choice 4 107 21.5%
eSCIP-Inf-1: Antibiotics within one hour before the first surgical cut 2 70 98.6%
eSCIP-Inf-9: Urinary catheter removed 2 259 88.0%
eSTK-02: Discharged on antithrombotic therapy 52 2,386 88.2%
eSTK-03: Anticoagulation therapy for atrial fibrillation/flutter 18 328 82.6%
eSTK-04: Thrombolytic therapy 22 170 68.8%
eSTK-05: Antithrombolytic therapy by end of hospital day two 54 1,600 86.8%
eSTK-06: Discharged on statin medication 74 2,473 72.4%
eSTK-08: Stroke education 36 1,118 75.9%
eSTK-10: Assessed for rehabilitation 50 2,634 77.4%
eVTE-1: VTE medicine/treatment 262 332,217 88.2%
eVTE-2: VTE medicine/treatment in ICU 234 88,668 94.3%
eVTE-3: VTE patients with overlap therapy 100 752 61.4%
eVTE-4: VTE patients with UFH monitoring 97 811 33.0%
eVTE-5: VTE discharge instructions 90 485 77.3%
eVTE-6: Incidence of potentially-preventable VTE* 71 171 4.7%
Table 2: Summary of values for eCQMs reported in 2016
The rate (%) for the proportion measures listed reflects the percentage of time that recommended care was provided.
The value (minutes) for the two eED measures reflects the time patients spend in the emergency department from their
arrival until admitted to the hospital, and the time it takes for a patient to be admitted to the hospital after being seen in
the emergency department.
No hospitals had cases to report for eAMI-7a: Fibrinolytic therapy within 30 minutes. Also, PC-05: Exclusive breast milk
feeding, and PC-05a: Exclusive breast milk feeding considering mother’s choice, are counted as one measure.
11
eCQM DATA SUMMARY (cont.)
*A lower score reflects better performance for this measure.
12
eCQM DATA SUMMARY (cont.)
List 2: 2016 electronic clinical quality measures (eCQMs)
Heart attack careeAMI-7a: Fibrinolytic therapy within 30 minutes
eAMI-8a: Primary PCI received within 90 minutes
Children’s asthma careeCAC-3: Home management plan of care
Emergency departmenteED-1a: Median time from ED arrival to ED departure for admitted ED patients
eED-2a: Admit decision time to ED departure time for admitted patients
Hearing screeningeEHDI-1a: Hearing screening prior to discharge
Perinatal careePC-01: Elective delivery
ePC-05/05a: Exclusive breast milk feeding
Surgical careeSCIP-INF-1: Antibiotics within one hour before the first surgical cut
eSCIP-INF-9: Urinary catheter removed
Stroke careeSTK-2: Discharged on antithrombotic therapy
eSTK-3: Anticoagulation therapy for atrial fibrillation/flutter
eSTK-4: Thrombolytic therapy
eSTK-5: Antithrombotic therapy by end of hospital day two
eSTK-6: Discharged on statin medication
eSTK-8: Stroke education
eSTK-10: Assessed for rehabilitation
Venous thromboembolism (VTE) careeVTE-1: VTE medicine/treatment
eVTE-2: VTE medicine/treatment in ICU
eVTE-3: VTE patients with overlap therapy
eVTE-4: VTE patients with UFH monitoring
eVTE-5: VTE discharge instructions
eVTE-6: Incidence of potentially-preventable VTE
These topic areas
are in alignment
with Centers
for Medicare &
Medicaid Services
(CMS) eCQMs. The
top three areas
(eED, eVTE and
eSTK) are eCQMs
that hospitals have
been reporting for
the longest time.
13
Composite measures combine the results of related
measures into a single percentage rating calculated by
adding up the number of times recommended evidence-
based care was provided to patients (measure numerator)
and dividing this sum by the total number of opportunities
to provide this care (measure denominator).
Composite for accountability measures: The number of
accountability measures used in the overall composite
rates varies each year. The 2016 overall accountability
composite calculation is derived from a total of 15
accountability measures from seven sets (inpatient
psychiatric services, venous thromboembolism (VTE)
care, stroke care, perinatal care, immunization, tobacco
use treatment, and substance use care). Two rate measures
from the inpatient psychiatric services set are not included
in the overall accountability composite. There are no VTE,
stroke or immunization measure set composites because
a measure set composite must have at least two measures
and these measure sets are comprised of only one
accountability measure. The heart attack and children’s
asthma care accountability measure sets included in last
year’s report have been retired. For more information, see
“Note on Calculations and Methodology.”
While the composite performance increased for all the
measure sets, the overall 2016 composite decreased due to
the retirement of 14 accountability measures.
Accountability composites for chart-based measures will
no longer be calculated after this year’s annual report
due to the retirement of a significant number of these
measures. An accountability composite rate based on so
few measures is not meaningful.
See Glossary for definitions.
Table 3: Measure set composite results for accountability measures
Accountability composite measure sets 2012 2013 2014 2015 2016
Inpatient psychiatric services composite 89.7% 90.3% 89.9% 90.3% 92.1%
Perinatal care composite 57.6% 74.1% 96.3% 97.6% 98.1%
Tobacco treatment composite N/A N/A 75.8% 84.2% 87.7%
Substance use composite N/A N/A 58.2% 77.5% 82.2%
Overall 97.6% 97.6% 97.2% 93.7%* 92.4%*
* The overall composite decreased starting in 2015 due to the retirement of high-performing measures.
Table 4: Percentage of hospitals achieving composite rates greater than 95 percent for accountability measure sets
Accountability composite measure sets 2012 2013 2014 2015 2016
Inpatient psychiatric services composite 51.4% 41.9% 43.7% 43.8% 54.9%
Perinatal care composite 1.3% 5.6% 73.4% 84.0% 88.1%
Tobacco treatment composite N/A N/A 9.7% 21.6% 28.8%
Substance use composite N/A N/A 3.2% 10.8% 15.9%
Overall 83.0% 81.1% 80.3% 61.0%* 59.6%*
Since implementation in 2002, the average number of hospitals reporting data was 3,262 and ranged from 3,073 to 3,419.* The overall composite decreased starting in 2015 due to the retirement of high-performing measures.
ACCOUNTABILITY MEASURES SUMMARY
14
eCQM DATA SUMMARY (cont.)
List 3: 2016 accountability measures
The 2016 overall
accountability
composite calculation
is derived from a total
of 15 accountability
measures from
seven sets (inpatient
psychiatric
services, venous
thromboembolism
(VTE) care, stroke
care, perinatal care,
immunization, tobacco
use treatment, and
substance use care).
Inpatient psychiatric servicesHBIPS-1: Admission screening
HBIPS-2: Physical restraint*
HBIPS-3: Seclusion*
HBIPS-5: Justification for multiple antipsychotic medications
Venous thromboembolism (VTE) careVTE-5: VTE warfarin discharge instructions
Stroke careSTK-4: Thrombolytic therapy
Perinatal carePC-01: Elective delivery
PC-03: Antenatal steroids
ImmunizationIMM-2: Influenza immunization
Tobacco use treatmentTOB-1: Tobacco use screening
TOB-2: Tobacco use treatment provided or offered
TOB-3: Tobacco use treatment provided or offered at discharge
Substance use careSUB-1: Alcohol use screening
SUB-2: Alcohol use brief intervention provided or offered
SUB-3: Alcohol and other drug use treatment provided or offered at discharge
* Rate measures not included in composite results
Performance measure 2012 2013 2014 2015 2016 2012-2016 difference (% points)
Inpatient psychiatric services composite 89.7% 90.3% 89.9% 90.3% 92.1% 2.4%
Admission screening 96.4% 96.7% 93.8% 93.3% 94.0% -2.4%
For age 1-12 years 98.1% 98.1% 98.1% 96.1% 95.4% -2.7%
For age 13-17 years 98.2% 98.4% 98.0% 96.3% 96.2% -2.0%
For age 18-64 years 95.6% 96.1% 93.2% 93.0% 93.7% -1.9%
For age 65 and above 95.9% 95.3% 87.6% 91.0% 92.4% -3.5%
Justification for multiple antipsychotic medications* 46.7% 52.7% 56.0% 62.1% 61.2% 14.5%
For age 1-12 years 51.5% 57.5% 56.2% 58.4% 62.8% 11.4%
For age 13-17 years 46.5% 50.5% 52.2% 59.0% 58.8% 12.3%
For age 18-64 years 46.7% 53.7% 56.9% 63.1% 62.0% 15.3%
For age 65 and above 47.0% 46.3% 51.2% 56.3% 56.1% 9.1%
Since implementation in 2009, the average number of hospitals reporting data was 718 and ranged from 244 to 2,076.
* The full name of the measure is “Multiple antipsychotic medications at discharge with appropriate justification — overall rate.”
Test measure; not included in the composite.
NATIONAL PERFORMANCE SUMMARY
15
Results are determined by the number of times the hospital met the measure divided by the number of opportunities
(eligible patients for the measure) the hospital had during the year. Results are expressed as a percentage.
All improvements or decreases in performance are statistically significant. Many of the smaller percentage
improvements occurred within large patient populations, meaning that significantly more patients received a treatment.
In some cases, performance was already quite high and there was less room for improvement.
Composite measures combine the results of all individual process measures on a similar medical condition into a single
percentage rating calculated by adding up the number of times recommended evidence-based care was provided to
patients and dividing this sum by the total number of opportunities to provide this care.
Composite for all measures: The composite for all measures calculation is derived from the accountability measures for
each measure set. These composite results have historically been provided in previous annual reports, allowing them to
be tracked from year to year. Any exclusions to the composite are noted with the tables.
See Glossary for definitions.
Table 5: Inpatient psychiatric services measure results
As in the other measure sets, high rates are preferred in this measure set for two of the measures. The overall measure
and rates are indicated in bold; the stratified measures (by specific age ranges of patients) are indicated in regular type.
Note: Admission screening became an accountability measure in 2014; it was a test measure in previous reports.
NATIONAL PERFORMANCE SUMMARY (cont.)
16
Table 6: Inpatient psychiatric services rate measure results
The following table includes two rate measures: physical restraint hours per 1,000 patient hours and seclusion hours per
1,000 patient hours. In addition, these two measures are stratified by age groups 1-12 years, 13-17 years, 18-64 years, and
age 65 and above. Lower rates reflect better performance.
The overall measure and rates are indicated in bold; the stratified measures (by specific age ranges of patients) are
indicated in regular type.
Performance measure 2012
Inpatient psychiatric services – ratio measures Median Maximum Percent of hospitals with 0 hours
Physical restraint (minutes per 1,000 patient hours)* 0.09 9.91 6.4%
For age 1-12 years 0.21 6.79 8.2%
For age 13-17 years 0.09 7.03 6.9%
For age 18-64 years 0.07 9.91 8.7%
For age 65 and above 0.00 17.44 42.8%
Seclusion (minutes per 1,000 patient hours)* 0.05 15.34 15.1%
For age 1-12 years 0.23 6.34 22.0%
For age 13-17 years 0.06 4.44 21.7%
For age 18-64 years 0.04 15.84 19.0%
For age 65 and above 0.00 2.93 72.1%
Performance measure 2013
Inpatient psychiatric services – ratio measures Median Maximum Percent of hospitals with 0 hours
Physical restraint (minutes per 1,000 patient hours)* 0.10 9.29 5.6%
For age 1-12 years 0.17 3.85 9.5%
For age 13-17 years 0.10 12.90 4.3%
For age 18-64 years 0.07 11.09 7.7%
For age 65 and above 0.00 7.88 44.7%
Seclusion (minutes per 1,000 patient hours)* 0.05 11.30 17.3%
For age 1-12 years 0.17 11.41 21.1%
For age 13-17 years 0.06 14.20 18.8%
For age 18-64 years 0.04 11.90 22.3%
For age 65 and above 0.00 6.13 73.3%
NATIONAL PERFORMANCE SUMMARY (cont.)
17
Performance measure 2014
Inpatient psychiatric services – ratio measures Median Maximum Percent of hospitals with 0 hours
Physical restraint (minutes per 1,000 patient hours)* 0.08 17.09 8.0%
For age 1-12 years 0.17 16.29 9.0%
For age 13-17 years 0.10 11.57 4.4%
For age 18-64 years 0.07 22.71 9.8%
For age 65 and above 0.00 6.47 47.6%
Seclusion (minutes per 1,000 patient hours)* 0.05 9.46 23.4%
For age 1-12 years 0.16 46.08 27.4%
For age 13-17 years 0.05 8.40 21.3%
For age 18-64 years 0.03 9.95 28.1%
For age 65 and above 0.00 11.96 69.1%
Performance measure 2015
Inpatient psychiatric services – ratio measures Median Maximum Percent of hospitals with 0 hours
Physical restraint (minutes per 1,000 patient hours)* 0.08 817.59 15.6%
For age 1-12 years 0.16 110.41 11.9%
For age 13-17 years 0.09 18.52 7.1%
For age 18-64 years 0.07 907.91 18.6%
For age 65 and above 0.00 811.24 50.3%
Seclusion (minutes per 1,000 patient hours)* 0.04 403.30 31.4%
For age 1-12 years 0.21 9.63 24.9%
For age 13-17 years 0.04 46.81 25.2%
For age 18-64 years 0.03 446.25 33.4%
For age 65 and above 0.00 155.40 73.6%
Table 7: Venous thromboembolism (VTE) care measure results
Performance measure 2012 2013 2014 2015 2016 2012-2016 difference (% points)
Venous thromboembolism (VTE)
VTE warfarin discharge instructions 82.2% 85.9% 92.3% 92.6% 92.9% 10.7%
Incidence of potentially-preventable VTE 4.2% 6.2% 4.6% 1.8% 1.8% -2.4%
Since implementation in 2010, the average number of hospitals reporting data was 913 and ranged from 59 to 2,639.
Test measure; not included in the composite. Also, a lower score reflects better performance for this measure, so the negative
performance point difference is favorable.
NATIONAL PERFORMANCE SUMMARY (cont.)
18
Performance measure 2016
Inpatient psychiatric services – ratio measures Median Maximum Percent of hospitals with 0 hours
Physical restraint (minutes per 1,000 patient hours)* 0.07 145.11 14.3%
For age 1-12 years 0.15 18.55 9.6%
For age 13-17 years 0.08 55.06 9.3%
For age 18-64 years 0.06 99.47 16.9%
For age 65 and above 0.00 269.57 49.6%
Seclusion (minutes per 1,000 patient hours)* 0.03 175.93 31.3%
For age 1-12 years 0.10 6.74 28.7%
For age 13-17 years 0.04 23.85 28.2%
For age 18-64 years 0.03 228.66 34.0%
For age 65 and above 0.00 33.03 71.8%
Since implementation in 2009, the average number of hospitals reporting data was 718 and ranged from 244 to 2,076.
* A lower ratio is preferred for this measure. Also, it is not included in the composite results because the denominator represents patient days
rather than patients, and therefore cannot be combined with the other measures.
Table 8: Stroke care measure results
Performance measure 2012 2013 2014 2015 2016 2012-2016 difference (% points)
Stroke care
Thrombolytic therapy 77.3% 79.1% 84.6% 87.1% 89.6% 12.3%
Since implementation in 2010, the average number of hospitals reporting data was 972 and ranged from 105 to 2,508.
NATIONAL PERFORMANCE SUMMARY (cont.)
19
Table 9: Perinatal care measure results
As in the other measure sets, high rates are preferred in this measure set for two of the measures. However, a lower score
reflects better performance on the Cesarean section, elective delivery, and newborn bloodstream infections measures.
Performance measure 2012 2013 2014 2015 2016 2012-2016 difference (% points)
Perinatal care composite 57.6% 74.1% 96.3% 97.6% 98.1% 40.5%
Antenatal steroids 81.8% 89.7% 91.8% 97.2% 97.8% 16.1%
Cesarean section* 26.3% 25.9% 26.8% 26.2% 26.1% -0.1%
Elective delivery* 8.2% 4.3% 3.3% 2.3% 1.9% -6.3%
Exclusive breast milk feeding** 50.8% 53.6% 49.4% 51.8% 52.9% 2.2%
Newborn bloodstream infections* N/A 2.5% 3.2% 2.4% 1.1% -1.4%
Since implementation in 2011, the average number of hospitals reporting data was 1,268 and ranged from 151 to 2,985.
* For this measure, a decrease in the rate is desired, so a negative percentage point difference is favorable.** This measure was included in the composite for 2012, but not subsequently.
This measure is an outcome measure and is not included in the composite. Only proportion process measures are included in the composite.
Table 10: Immunization measure results
Performance measure 2012 2013 2014 2015 2016 2012-2016 difference (% points)
Immunization
Influenza immunization 86.2% 89.9% 95.2% 94.1% 94.3% 8.2%
Since implementation in 2012, the average number of hospitals reporting data was 1,313 and ranged from 78 to 2,741.
Table 11: Tobacco use treatment measure results
Performance measure 2014 2015 2016 2014-2016 difference (% points)
Tobacco use treatment composite 75.8% 84.2% 87.7% 11.9%
Tobacco use screening 94.1% 97.8% 98.6% 4.5%
Tobacco use treatment provided or offered 51.2% 60.5% 70.3% 19.1%
Tobacco use treatment provided or offered at discharge 36.4% 40.6% 48.9% 12.5%
Since implementation in 2014, the average number of hospitals reporting data was 914 and ranged from 68 to 2,011.
NATIONAL PERFORMANCE SUMMARY (cont.)
20
Table 12: Substance use care measure results
Performance measure 2014 2015 2016 2014-2016 difference (% points)
Substance use care composite 58.2% 77.5% 82.2% 24.0%
Alcohol use screening 58.2% 82.5% 86.7% 28.4%
Alcohol use brief intervention provided or offered 48.2% 58.3% 69.8% 21.6%
Alcohol and other drug use treatment provided or offered at discharge 62.6% 66.9% 69.0% 6.5%
Since implementation in 2014, the average number of hospitals reporting data was 271 and ranged from 130 to 513.
Table 13: Percentage of hospitals achieving 95 percent or greater performance
The following table shows percentage of hospitals achieving the annual targeted performance of 95 percent or more
compliance on a measure. The last column is reported as percentage points – the difference on a percentage scale be-
tween two rates, in this case 2015 performance versus 2016 performance.
Performance measure 2014 High 2015 High 2016 High 2015-2016 (% >95) (% >95) (% >95) difference (% points)
Alcohol use screening (Substance use care) 16.8% 33.7% 51.8% 18.0%
Tobacco use screening (Tobacco use treatment) 59.0% 84.8% 92.1% 7.3%
Tobacco use treatment provided or offered (Tobacco use treatment) 2.6% 15.4% 20.9% 5.5%
Thrombolytic therapy (Stroke) 47.1% 57.5% 62.1% 4.6%
Alcohol use brief intervention provided or offered (Substance use care) 12.1% 18.5% 22.0% 3.4%
Elective delivery (Perinatal)* 77.1% 85.4% 88.7% 3.4%
Admission screening (Inpatient psychiatric) 65.4% 65.2% 67.3% 2.1%
Tobacco use treatment provided or offered at discharge (Tobacco use treatment) 0.0% 6.4% 8.5% 2.1%
Antenatal steroids (Perinatal) 72.5% 92.2% 94.2% 2.0%
Alcohol and other drug use treatment provided or offered at discharge (Substance use care) 1.9% 3.1% 3.7% 0.6%
Influenza immunization (Immunization) 70.3% 66.4% 66.4% 0.0%
Exclusive breast milk feeding (Perinatal) 0.4% 0.5% 0.2% -0.3%
Incidence of potentially-preventable VTE (VTE)* 66.3% 90.7% 89.4% -1.3%
VTE warfarin discharge instructions (VTE) 59.5% 63.0% 61.4% -1.6%
Justification for multiple antipsychotic medications (Inpatient psychiatric) 11.5% 17.3% 12.6% -4.7%
* For this measure, a decrease in the rate is desired, so the percentage represented is the percent of hospitals with percentage of 5 percent or less.
• Test measure; not included in the composite.
21
STATE MAPS
The following maps show measure performance from the first full year that data was reported compared to
2016 performance.
State maps 1: Inpatient psychiatric services measures
Admission Screening
Justification for Multiple Antipsychotic Medications
22
State maps 2: Venous thromboembolism (VTE) care measure
VTE Warfarin Discharge Instructions
Thrombolytic Therapy
STATE MAPS (cont.)
State maps 3: Stroke care measures
23
State maps 4: Perinatal care measures
Antenatal Steroids
Elective Delivery
STATE MAPS (cont.)
24
Influenza Immunization
Tobacco Use Screening
STATE MAPS (cont.)
State maps 6: Tobacco use treatment measures
State maps 5: Immunization measure
25
Tobacco Use TreatmentProvided or Offered
STATE MAPS (cont.)
State maps 6: Tobacco use treatment measures (cont.)
Tobacco Use Treatment Provided or Offered at Discharge
26
Alcohol Use Screening
STATE MAPS (cont.)
State maps 7: Substance use care measures
Alcohol Use Brief Intervention Provided or Offered
27
Alcohol and Other Drug Use Treatment Provided or Offered at Discharge
STATE MAPS (cont.)
State maps 7: Substance use care measures (cont.)
28
This annual report includes results on ORYX® quality
of care measures reported upon by Joint Commission-
accredited hospitals and critical care hospitals during 2016.
Reporting on these measures aligns The Joint Commission
as closely as possible to the Centers for Medicare &
Medicaid Services (CMS) Hospital Inpatient Quality
Reporting Program.
Why quality of care measures were created, what they report and why the results are important
The Joint Commission has been involved in performance
measurement for 27 years, viewing it as a critical way to
extend the reach and sophistication of the accreditation
process. The Joint Commission’s 1990 publication, The
Primer on Clinical Indicator Development and Application,
created a readily adaptable template for performance
measure development that is still in use today and
established The Joint Commission as a leader in this arena.
The Joint Commission continues to be a leader in
performance measurement. The data displayed on the CMS
Hospital Compare website reflects many measures that
The Joint Commission and CMS have in common. A large
percentage of that data comes from The Joint Commission
via its well-established performance measure data
network. Today, this network comprises approximately
31 measurement systems, all under contract to The Joint
Commission, and is the source of quality-related data on
The Joint Commission’s Quality Check® website
(www.qualitycheck.org).
America’s Hospitals: Improving Quality and Safety –
The Joint Commission’s Annual Report 2017 presents the
overall performance of Joint Commission-accredited
hospitals on quality of care for chart-based measures
relating to inpatient psychiatric services, venous
thromboembolism (VTE) care, stroke care, perinatal care,
immunization, tobacco use treatment, and substance
use care. These measures were chosen because they
provide concrete data about the best kinds of treatments
or practices for common conditions for which Americans
enter the hospital and seek care.
UNDERSTANDING THE QUALITY OF CARE MEASURES
The results are important, because they show that
hospitals have improved their care quality. The results
identify opportunities for further improvement, and
support continual measurement and reporting. Quality
improvement in hospitals contributes to saved lives, better
health, and quality of life for many patients, as well as
lower health care costs.
2016 ORYX® performance measure reporting requirements
During 2016, Joint Commission-accredited hospitals had
continued flexibility in meeting the ORYX® performance
measure requirements for reporting on a minimum of six
measure sets. Only one measure set – perinatal care – was
mandatory as one of the six measure sets for hospitals.
The threshold for mandatory reporting on the perinatal
care measure set was reduced to 300 or more live births
per year (previously, it was 1,100 live births per year).
Accredited hospitals had the flexibility of meeting ORYX®
reporting requirements through one of three options:
• Option 1: Vendor submission of quarterly data on six of
nine sets of chart-abstracted measures.
• Option 2: Vendor submission of data on six of eight sets
of eCQMs.*
• Option 3: Vendor submission of data on six measure
sets using a combination of chart-abstracted measures
and eCQMs.*
*For 2016, hospitals could report on as few as one eCQM in an
eCQM set and it was counted as an eCQM set.
29
UNDERSTANDING THE QUALITY OF CARE MEASURES (cont.)
A special focus on accountability measures
Accountability measures are evidence-based care
processes closely linked to positive patient outcomes. These
measures are most suitable for use in programs that hold
providers accountable for their performance to external
oversight entities and to the public. There has been an
evolution of such oversight programs – including those for
value-based purchasing, accreditation, certification, and
public reporting – and they are often used to demonstrate
quality and cost-efficient performance, to drive market
share, and to determine appropriate reimbursements.
Each accountability measure meets four criteria that
evaluate whether or not evidence-based care processes
associated with the measures lead to positive patient
outcomes. As new measures are introduced, they are
evaluated against the criteria.
For more information about accountability measures,
see the New England Journal of Medicine article
“Accountability Measures – Using Measurement to
Promote Quality Improvement,” for which Mark R.
Chassin, MD, FACP, MPP, MPH, president and chief
executive officer of The Joint Commission, was the
lead author.
Also see the Annals of Internal Medicine article, “Holding
Providers Accountable for Health Care Outcomes,” by Dr.
Chassin and lead author David W. Baker, MD, MPH, FACP,
executive vice president in the Division of Health Care
Quality Evaluation at The Joint Commission. This latter
article suggests a national critical look is needed on
how to assess the validity of outcome measures used
by public accountability programs. Outcome measures
are intended to quantify the end results of a health care
service or intervention. Yet, criteria for assessing whether
they are accurate and valid enough to use for public
reporting, payment and other accountability programs are
not well defined.
It’s important to note that where a patient receives care
makes a difference. Not all hospitals deliver the same level
of quality; some hospitals perform better than others in
treating particular conditions and in achieving patient
satisfaction. This variability has been known within
the hospital industry for a long time. Designation as an
accountability measure is included in the information on
Quality Check® (www.qualitycheck.org).
How quality measures are determined
The Joint Commission worked closely with clinicians,
health care providers, hospital associations, performance
measurement experts, and health care consumers
across the nation to identify the quality measures. This
collaborative process identified measures that reflect the
best “evidence-based” treatments relating to inpatient
psychiatric services, VTE care, stroke care, perinatal care,
immunization, tobacco use treatment, and substance
use care. Current measures are the product of The Joint
Commission’s Hospital Core Measure Initiative that sought
to create sets of standardized national measures that would
permit comparisons across organizations. Subsequently,
The Joint Commission collaborated with CMS to align
common measures to ease data collection efforts by
hospitals and to allow the same data sets to be used to
satisfy multiple data requirements.
Related quality reporting efforts of other organizations
The CMS Hospital Compare website (www.
hospitalcompare.hhs.gov) reports quality information
from over 4,000 Medicare-certified U.S. hospitals,
including treatments relating to cataracts, colonoscopy,
30
UNDERSTANDING THE QUALITY OF CARE MEASURES (cont.)
heart attack, emergency department care, preventative
care (immunization), stroke care, blood clot prevention,
perinatal care, and medical imaging. Hospital Compare also
includes information on patient experiences, readmissions,
complications, deaths, and payment and value of care.
In addition, CMS in 2013 began receiving data on The Joint
Commission’s perinatal care elective delivery measure,
which was adopted for use in the CMS Hospital Inpatient
Quality Reporting Program, and now around 3,300
hospitals are submitting data to CMS on this measure.
Joint Commission-developed measures also have been
adopted into a number of CMS quality reporting programs.
Today, Joint Commission/CMS common measures and
Joint Commission-only measures are used in the CMS
Hospital Inpatient Quality Reporting Program, Hospital
Outpatient Quality Reporting Program, Hospital Value-
Based Purchasing Program, Inpatient Psychiatric Facility
Quality Reporting (IPFQR) Program and the Medicare &
Medicaid EHR Incentive Program for eligible Hospitals/
Critical Access Hospitals. The Joint Commission-developed
hospital-based inpatient psychiatric services (HBIPS)
measures were adopted as the initial set of measures for
the CMS IPFQR Program with other Joint Commission-
developed measures subsequently adopted (i.e., tobacco
use treatment and substance use care).
Consumers can use Hospital Compare to compare care
of local hospitals to state and national averages. Unlike
Quality Check®, Hospital Compare includes data from
organizations accredited by CMS-recognized accrediting
organizations other than The Joint Commission and some
unaccredited organizations. Hospital Compare does not
currently include Department of Defense and Indian
Health Service hospitals.
The National Quality Forum’s National Quality
Partners (NQP) engages its members – including The
Joint Commission – in health care quality issues of
national importance.
Data collection and reporting requirements
For 2016, The Joint Commission required most hospitals
to select six measure sets. Hospitals chose sets best
reflecting their patient population and reported on all
the applicable measures in each of the sets they choose.
Hospitals submitted monthly data on a quarterly basis
Criteria for accountability process measures
Research: Strong scientific evidence demonstrates
that performing the evidence-based care process
improves health outcomes (either directly or by
reducing risk of adverse outcomes).
Proximity: Performing the care process is closely
connected to the patient outcome; there are
relatively few clinical processes that occur after
the one that is measured and before the improved
outcome occurs.
Accuracy: The measure accurately assesses
whether or not the care process has actually been
provided. That is, the measure should be capable
of indicating whether the process has been
delivered with sufficient effectiveness to make
improved outcomes likely.
Adverse Effects: Implementing the measure
has little or no chance of inducing unintended
adverse consequences.
31
UNDERSTANDING THE QUALITY OF CARE MEASURES (cont.)
on all measures of performance within specific sets they
choose to third-party vendors, which compiled and
provided data to The Joint Commission. Hospitals can
obtain feedback reports through The Joint Commission’s
Connect™ extranet.
Note on calculations and methodology
This report includes a composite for accountability
measures: the sum of all the numerator counts for
accountability process measures across all measure sets
divided by the sum of all the denominator counts from
across the same accountability measures.
In addition, a composite measure for a measure set is
calculated by adding or “rolling up” the number of times
recommended care was provided over all the process
measures in the given measure set and dividing this sum
by the total number of opportunities for providing this
recommended care, determined by summing up all of the
process measure populations for this same set of measures.
The composite measure shows the percentage of the time
that recommended care was provided.
For example, if a tobacco use treatment patient receives
each treatment included in the tobacco use treatment
measure set, that’s a total of three treatments in three
opportunities. If 60 patients receive all three treatments,
that’s 180 treatments in 180 opportunities – 100 percent
composite performance. However, if some of the 60
patients don’t receive all three treatments, and the
treatments given to the 60 patients add to a total of 170, the
tobacco use treatment composite score is 94 percent.
Composite performance measures are useful in integrating
performance measure information in an easily understood
format that gives a summary assessment of performance
for a given area of care in a single rate. The composite
measures in this report are based on combining all of
the process rate-based accountability measures in the
measure set or the accountability measures across measure
sets with more than one measure. For a performance
measure, each patient identified as falling in the measure
population can be considered an opportunity to provide
recommended care.
While the composite performance increased for all the
measure sets, the overall 2016 composite decreased due to
the retirement of 14 measures.
Accountability composites for chart-based measures will
no longer be calculated after this year’s annual report
due to the retirement of a significant number of these
measures. An accountability composite rate based on so
few measures is not meaningful.
Inclusions and exclusions
This report only includes data about patients considered
“eligible” for one of the evidence-based treatments or
measures. It’s important to understand that not every
patient gets – or should get – a treatment. Often, patients
have health conditions or factors that influence the
effectiveness of treatments, or whether or not a provider
orders a particular treatment. Also, a patient may choose to
refuse treatment or not follow the instructions of his or her
care plan.
Links for more information
The Joint Commission:
www.jointcommission.org
Pioneers in Quality™:
www.jointcommission.org/topics/pioneers_in_quality.aspx
Quality Check®:
www.qualitycheck.org
32
GLOSSARY
Accountability process measure. An accountability process
measure is a quality measure that meets four criteria designed
to identify measures that produce the greatest positive impact
on patient outcomes when hospitals demonstrate improvement.
The four criteria are: research, proximity, accuracy and
adverse effects (see Page 30 for an explanation of the criteria).
Accountability measures are a subset of core measures (see
core measure).
Admission screening. Evaluating a patient for violence risk,
substance use, psychological trauma history and patient
strengths within the first three days of admission to an inpatient
psychiatric facility.
Antenatal steroids. Medication given to a mother in premature
labor before delivery to promote lung development in the baby.
Antithrombotic therapy. Pharmacologic agents (oral or
parenteral) that prevent or interfere with the formation
of a blood clot.
Cesarean section. A surgical procedure in which an abdominal
incision is made to deliver the infant.
Composite measure. A measure that combines the results
of two or more process measures into a single rating. A
composite is a summary of a related set of measures, which
could be a condition specific set, all accountability measures,
or accountability and non-accountability measures. However,
accountability composites are restricted to accountability
measures; non-accountability measures are excluded.
Continuous variable measure. A type of measure in which
the value of each measurement can fall anywhere along a
continuous scale (e.g., the time [in minutes] from hospital arrival
to administration of a medication).
Core measure. A core measure is a standardized quality
measure with precisely defined specifications that can be
uniformly embedded in different systems for data collection
and reporting. A core measure must meet Joint Commission-
established attributes, such as: targets improvement in
population health, precisely defined and specified, reliable, valid,
interpretable, useful in accreditation, under provider control,
and public availability.
Elective delivery. A delivery occurring between 37 and 39 weeks of
gestation, without a medical reason.
Electronic Clinical Quality Measure (eCQM). A clinical quality
measure that is specified in a standard electronic format and is
designed to use structured, encoded data present in the electronic
health record.
Evidence-based care. Using current best evidence in making
decisions about the care of individual patients or in the delivery of
health services.
Exclusive breast milk feeding. An infant receives only breast milk
during the hospital stay, with no additional food or drink, including
water.
Fibrinolytic therapy. Medication that dissolves blood clots. Breaking
up blood clots increases blood flow to the heart. If blood flow is
returned to the heart muscle quickly during a heart attack, the risk
of death is decreased.
Health care-associated infections in newborns. An infection
acquired during a newborn’s stay in a hospital.
Inpatient psychiatric services. Inpatient psychiatric services include
care provided to a patient for a mental disorder while hospitalized
in a psychiatric unit of an acute care hospital or a free-standing
psychiatric hospital. Services rendered to outpatients or “day
treatment” patients are not considered inpatient psychiatric services.
Median. The value in a set of observations whose values are
arranged from smallest to largest that divides the data into two
parts of equal size (e.g., if looking at the time [in minutes] from
hospital arrival to administration of a medication and the ranked
observations were 5, 10, 20, 30 and 40 minutes, the median would
be 20 minutes).
Multiple antipsychotic medications. Antipsychotic medications
are drugs prescribed to treat mental disorders; if two or more
medications are routinely administered or prescribed, it is
considered multiple medications.
Outcomes measure. A measure that focuses on the results of
the performance or nonperformance of a process. (See
process measure.)
33
Overlap therapy. Administration of parenteral (intravenous or
subcutaneous) anticoagulation therapy and warfarin to treat
patients with VTE.
PCI therapy. PCI stands for “percutaneous coronary
interventions.” PCI therapy is a coronary angioplasty procedure
performed by a doctor who threads a small device into a clogged
artery to open it, thereby improving blood flow to the heart. A
lack of blood supply to the heart muscle can cause lasting heart
damage. PCI therapy is used as an alternative treatment to
coronary artery bypass graft surgery (CABG).
Percentage points. This is the difference on a percentage scale
between two rates expressed as percentages. For example, the
difference between a performance rate of 85 percent and a
performance rate of 92 percent is 7 percentage points.
Perinatal. The period shortly before and after birth.
Perioperative. This generally refers to 24 hours before surgery
and lasts until the patient leaves the recovery area.
Physical restraint. A physical restraint is any manual or physical
or mechanical device, material, or equipment that immobilizes
a patient or reduces the ability of a patient to move his or her
arms, legs, body or head freely. A physical restraint is used as a
restriction to manage a patient’s behavior or restrict the patient’s
freedom of movement and is not a standard treatment for the
patient’s medical or psychiatric condition.
Process measure. A measure that focuses on one or more steps
that lead to a particular outcome. (See outcomes measure.)
Prophylaxis. Any medical intervention designed to preserve
health and prevent disease.
Range. The smallest and largest values in a set of data (e.g.,
if looking at the time [in minutes] from hospital arrival to
administration of a medication and the values from the ranked
observations were 5, 10, 20, 30 and 40 minutes, the range would
be 5,40 minutes). The range can also be defined as a single number,
the difference between the smallest and largest values (e.g., 40 – 5
= 35 minutes in the example).
Rehabilitation assessment. Evaluation of the need for or receipt of
rehabilitation services. Rehabilitation is a treatment or treatments
designed to facilitate the process of recovery from injury, illness or
disease to as normal a condition as possible.
Seclusion. Seclusion is the involuntary confinement of a patient
alone in a room or an area where the patient is physically
prevented from leaving.
Statin. A class of pharmaceutical agents that lower blood
cholesterol. Specifically, the agents modify LDL-cholesterol
by blocking the action of an enzyme in the liver which is
needed to synthesize cholesterol, thereby decreasing the level
of cholesterol in the blood. Statins are also called HMG-CoA
reductase inhibitors.
Test measure. A measure being evaluated for reliability
of the individual data elements or awaiting National Quality
Forum endorsement.
Thrombolytic therapy. Administration of a pharmacological
agent intended to cause lysis of a thrombus (destruction or
dissolution of a blood clot).
Top 10 percent. For measure reporting, this indicates the value
(number) at which one-tenth of the recorded values are at this
value or better (e.g., if looking at the time [in minutes] from
hospital arrival to administration of a medication and the values
from the ranked observations, a top 10 percent value of 151 would
indicate that one-tenth of reporting hospitals have a measure
value of 151 or less).
UFH monitoring. Using a protocol or nomogram to ensure that
UFH (unfractionated heparin) achieves a sufficient level of anti-
coagulation.
VTE. VTE stands for venous thromboembolism and is when a
blood clot forms in a deep vein in the body, such as in the leg. VTE
is a common complication at surgery, and hospitalized medical
patients – particularly those who have decreased mobility – are at
risk for development of VTE.
GLOSSARY (cont.)