The Joint Commission 2016 Annual Report

1. Hospital performance on accountability measures continued to improve, 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 number of accountability measures included in this year’s report is 29, down from 49 in 2014. The Joint Commission retired 20 accountability measures effective December 31, 2014, due to excellent quality performance by Joint Commission-accredited hospitals on these measures, and to maintain alignment as closely as possible with the CMS Hospital Inpatient Quality Reporting Program. In addition, the retirement of the measures was made to reduce the burden of reporting on organizations, and help them to focus on areas where opportunities to improve exist. The report also includes performance data on three non-accountability measures noted within the measure sets (PC-05: Exclusive breast milk feeding, VTE-6: Hospital-acquired potentially-preventable venous thromboembolism (VTE), and HBIPS-4: Multiple antipsychotic medications at discharge).

Accountability measure composite performance summary

This year’s report includes accountability measure results for inpatient psychiatric services, venous thromboembolism (VTE) care, stroke care, perinatal care, tobacco use treatment, and substance use care. In 2015, improvements on individual measures have ranged from small fractions of a percentage point to 24.3 percentage points. Relatively small percentage-point improvements in 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 2015 inpatient psychiatric services result is 90.3 percent, up from 87.3 percent in 2011 – an improvement of 3.0 percentage points.
• The 2015 VTE care result is 95.2 percent, up from 89.9 percent in 2011 – an improvement of 5.3 percentage points. As a result of this excellent performance, three of four individual VTE care accountability measures were retired effective December 31, 2015.
• The 2015 stroke care result is 97.7 percent, up from 94.9 percent in 2011 – an improvement of 2.8 percentage points. As a result of this excellent performance, seven of eight individual stroke care accountability measures were retired effective December 31, 2015.
• The perinatal care result is 97.6 percent, up from 53.2 percent in 2011 – an improvement of 44.4 percentage points.
• The tobacco use treatment result is 84.2 percent, up from 75.8 percent in 2014 – an improvement of 8.4 percentage points.
• The substance use care result is 77.5 percent, up from 58.2 percent in 2014 – an improvement of 19.3 percentage points.

In addition, two measure sets had only one measure each and therefore no composite result, since a composite must include at least two measures. The following two measures, however, were included in the overall accountability composite results
(see graph 1).

• The children’s asthma care home management plan of care measure result is 87.8 percent, up from 84.3 percent in 2011 – an improvement of 3.5 percentage points. This measure was retired effective December 31, 2015.
• The influenza immunization result is 94.1 percent, up from 86.2 percent in 2012 – an improvement of 7.9 percentage points.

Composite accountability measures have been compiled for inpatient psychiatric services, VTE and stroke care since 2011, for perinatal care 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.” 

2. Flexible options for reporting eCQMs and chart-abstracted measures introduced

2015 saw the introduction of flexible options for reporting electronic clinical quality measures (eCQMs), chart-abstracted measures, or both during 2015. These reporting options align The Joint Commission as closely as possible to the CMS Hospital Inpatient Quality Reporting Program. During 2015, there were 21 available eCQMs from which Joint Commission-accredited hospitals could select and report performance data. To support hospitals in making the transition to eCQM reporting, The Joint Commission introduced the Pioneers in Quality™ program and coordinated it with the Core Measure Solutions Exchange^®.  

3. The 2015 composite accountability score declined due to the retirement of many measures

The Joint Commission illustrates improvement with a “composite” result, which sums up the results of individual accountability process measures into a single summary score. Due to the retirement of many measures on which hospitals were performing extremely well, the 2015 overall composite score on accountability measures is 93.7 percent, down from 97.2 in 2014. For the same reason, the percentage of hospitals achieving 95 percent declined to 61 percent, down from 80.3 percent in 2014. The overall composite accountability score reflects 34.7 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 2014 and 2015 composite scores.

Measure sets with composite performance below the overall composite rate of 93.7 percent are inpatient psychiatric services (90.3 percent), tobacco use treatment (84.2 percent), and substance use care (77.5 percent). The result of 61 percent of hospitals achieving composite measure performance greater than 95 percent is different than the 93.7 percent overall accountability composite measure performance. The 93.7 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 61 percent result measures the percentage of hospitals achieving overall composite performance greater than 95 percent.

Pioneers in Quality™ will enable Joint Commission-accredited hospitals to maintain alignment with the eCQMs the Centers for Medicare & Medicaid Services utilizes in its Hospital Inpatient Quality Reporting Program. Another key step in this alignment was The Joint Commission’s flexible reporting option – introduced in 2015 – that allowed accredited hospitals to choose which measure sets to report and allowed for submission of chart-abstracted measures, eCQMs, or a combination of chart-abstracted and eCQMs. The Joint Commission retired several chart-based measures in 2015, as the move toward eCQMs continues.

2016 recognition of eCQM contributors
During this initial year of the Pioneers in Quality™ program, The Joint Commission is recognizing accredited hospitals that have assisted The Joint Commission in the evolution and utilization of eCQMs. Specifically, hospitals are being recognized for the following three “pioneering” contribution areas:  

• Expert Contributor: Hospitals that advance the evolution and utilization of eCQMs through such contributions as presenting at a Pioneers in Quality™ webinar or participating in eCQM development.
• Solution Contributor: Hospitals that submit an eCQM solution or implementation story to the Core Measure Solution Exchange^®.
• Data Contributor: Hospitals that transmit eCQM data into the production database by the 2016 submission date.

PIONEERS IN QUALITY WEBSITE

This program recognizes eCQM data transmission and its support by contributors only. The program is not intended to connote data quality or quality of care. Recognition as a contributor in these three areas is for 2016 only. Within the coming months, The Joint Commission plans to introduce a recognition program for “pioneering” hospitals in the evolution and use of eCQMs, with this report used as a vehicle to promote and communicate these “pioneers” each year. New criteria will be developed as a part of that program. See the 2016 eCQM contributors being recognized by The Joint Commission. 

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 33 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 2016 presents the overall performance of Joint Commission-accredited hospitals on quality of care core measures relating to children’s asthma, 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. 

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. 

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. 

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 children’s asthma care, 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 heart attack, heart failure, pneumonia, surgical care, emergency department care, preventative care (immunization), children’s asthma care, stroke care, VTE care, perinatal care, and medical imaging. Hospital Compare also includes information on 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 more than 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 (both Stage 1 and Stage 2). 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., substance use care and tobacco use treatment). 

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 2015, 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 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 stroke care patient receives each treatment included in the stroke care measure set, that’s a total of eight treatments in eight opportunities. If 60 patients receive all eight treatments, that’s 480 treatments in 480 opportunities – 100 percent composite performance. However, if some of the 60 patients don’t receive all eight treatments, and the treatments given to the 60 patients add to a total of 470, the stroke composite score is 98 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. 

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. 

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 the sidebar box in the “Understanding the quality of care measures” section of this report 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.

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.

Observation patient. A status designated to patients who are rendered care in a hospital setting and observed for worsening symptoms to determine whether or not they need to be admitted for continued care as an inpatient.

ORYX Performance Measure Report (PMR). The ORYX Performance Measure Report is designed to support and help guide Joint Commission-accredited hospitals in their performance assessment and improvement activities through the use of summary dashboards and comprehensive measure details depicting the organization’s performance on each core measure set and measure on which The Joint Commission receives data for the organization. The report also highlights an organization’s compliance with Standard PI.02.01.03 that sets an 85 percent accountability composite rate threshold based on the past four quarters of accountability measure data. (Note: This standard has been temporarily suspended.) ORYX PMRs are updated quarterly and made available to accredited hospitals through the secure Joint Commission Connect extranet site.

Outcomes measure. A measure that focuses on the results of the performance or nonperformance of a process. (See process measure.)

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 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.

PMR. See ORYX Performance Measure Report.

Post discharge continuing care plan. Communication from the hospital to the next health provider after a patient is discharged from the hospital. The plan must contain the reason for hospitalization, main diagnosis at discharge, a list of medications at discharge, and recommendations for the next level of care.

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.

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.

Developed as a benefit for Joint Commission-accredited hospitals, the Core Measure Solution Exchange^® promotes the sharing of performance measurement success stories among peer hospitals. Select eCQM implementation stories from the exchange will be featured on the Pioneers in Quality™ portal.

About 266 solutions have been posted by hospitals having dramatically improved and sustained their performance. To submit or search for solutions, access the exchange via Joint Commission Connect™. To submit your own eCQM experiences, see these instructions before accessing the exchange. You may also participate in discussions about the solutions, rate the usefulness and transferability of the solutions, post adapted versions of the solutions based upon your own experience, and sign up for email notifications when new measure solutions are posted. You may also send questions and comments to solutionexchange@jointcommission.org.

Results are determined by the number of times the hospital met the measure (such as developing a home management plan of care for a pediatric asthma patient) 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.