America’s Hospitals

Improving Quality and Safety

Leaders’ letter

Mark R. Chassin, MD

Mark R. Chassin, MD

David Baker, MD

David Baker, MD

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

Baker%2C David e-Signature

David W. Baker, MD, MPH, FACP
Executive Vice President
Division of Health Care Quality Evaluation
The Joint Commission

 

Mission Statement

Vision:
All people always experience the safest, highest quality, best-value health care across all settings.

Mission:
To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

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.

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Executive Summary

Graph 1: Percent of hospitals with overall accountability composite 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.

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.

      Pioneers in Quality Web Portal

Click here to view 2017 Pioneers in Quality™
Expert and Solution Contributors

eCQM Data Summary

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.

Click here to view 2016 electronic clinical quality measures (eCQMs)

 

 

 

 

 

 

 

 

Accountability measures summary

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.

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).

Joint Commission-accredited hospitals had excellent performance on the 2016 perinatal care measure result at 98.1%.

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Understanding quality of care measures

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.

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