America’s Hospitals: Improving Quality and Safety...hospitals perform better than others in treating particular conditions. More than 3,200 Joint Commission-accredited hospitals

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

http://www.qualitycheck.org

https://www.jointcommission.org/topics/pioneers_in_quality.aspx

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



• The influenza immunization measure result is 94.3



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


https://www.qualitycheck.org



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


*A lower score reflects better performance for this measure.

12


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


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%




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%


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%


17




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%


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%




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%


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


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%


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.


18




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%


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%


* 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


Stroke care

Thrombolytic therapy 77.3% 79.1% 84.6% 87.1% 89.6% 12.3%



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.


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


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%



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,

http://www.nejm.org/doi/pdf/10.1056/NEJMsb1002320

http://www.nejm.org/doi/pdf/10.1056/NEJMsb1002320

http://annals.org/aim/article/2648599/holding-providers-accountable-health-care-outcomes

http://annals.org/aim/article/2648599/holding-providers-accountable-health-care-outcomes


http://www.hospitalcompare.hhs.gov

http://www.hospitalcompare.hhs.gov

30


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


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

http://www.jointcommission.org

http://www.jointcommission.org/topics/pioneers_in_quality.aspx


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.)

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