Hospitals may publicize their performance on the National Quality Improvement Goals. Most hospitals accredited by The Joint Commission submit data on their performance in several areas as a requirement of accreditation. Some small hospitals where the sample size is too small to draw any formative conclusions; and specialty hospitals where the existing measures are not necessarily appropriate are excluded from submitting data. The goals track outcomes for common conditions such as heart attack, heart failure, pregnancy, pneumonia, and surgical infections. Health care providers and practitioners recognize these goals as optimal care for treating patients with the identified conditions.
For example, for a patient who suffers a heart attack, the hospital should follow these National Quality Improvement Goals, if appropriate:
- Place the patient on aspirin upon arrival to the hospital.
- Assure that the patient is discharged from the hospital on aspirin.
- Give the patient advice and education to stop smoking.
- Give the patient a prescription for a beta blocker.
Heart attack care is an example of a National Quality Improvement Goal measure set. “Aspirin on arrival” is a measure within the heart attack care measure set.
Understanding the National Quality Improvement Goals
Your hospital’s results on National Quality Improvement Goal measures and measure sets are displayed in its Quality Report. Quality Reports became publicly available in 2004. Data are updated on a quarterly basis.
Your hospital’s measure set results (for example heart attack care) are reported with symbols, comparing your hospital’s performance with other Joint Commission-accredited hospitals nationwide and statewide.
Your hospital’s individual measure results (for example aspirin upon arrival) are reported by using symbols and benchmark scores, comparing your hospital to other Joint Commission-accredited hospitals nationwide and statewide.
View an example for the measure "Aspirin at Arrival."
(Requires Adobe Reader)
What hospitals may publicize
Your hospital may publicize its performance on the measures and measure sets, including how it performed compared to other accredited hospitals nationwide and statewide.
Guidelines
- State the date ranges of the results your organization wants to publicize. For example: “National Quality Improvement Goal results for 2006” or “for October 2005 to September 2006.”
- State that the latest data are available on Quality Check at www.qualitycheck.org.
- Your organization may not publicize its performance on a single measure without stating the organization’s performance on the measure set. For example, if you want to publicize that your hospital administered aspirin at arrival 99 percent of the time, you must also state that your hospital:
- Achieves the best possible results for heart attack care, or
- Performs above most Joint Commission-accredited hospitals on heart attack care, or
- Performs similar to most Joint Commission-accredited hospitals on heart attack care, or
- Performs below most Joint Commission-accredited hospitals on heart attack care.
- State that your organization’s performance was “above 90 percent but was below most other organizations” as applicable. Some measures such as aspirin at arrival have very high compliance rates (100 percent). Therefore it is possible to get a minus with a score of 92 percent. The Quality Report will state that such a hospital "scored above 90 percent but was below most other organizations.”
The minimum cases required
The Joint Commission has established a minimum case threshold of 30 cases for process measures. A process measure is a measure that focuses on a process which leads to a certain outcome, meaning that a scientific basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome. If a hospital does not reach the threshold number of cases, Quality Check will not interpret the results by assigning a plus, minus or check symbol.
National Quality Improvement Goals and the Hospital Quality Alliance
The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) are two distinct organizations that are dedicated to collecting and reporting health care information to the public. The Joint Commission is an independent, not-for-profit organization, and CMS is a federal agency within the U.S. Department of Health and Human Services. CMS reports data for hospitals participating in the Hospital Quality Alliance, which includes Joint Commission accredited hospitals as well as hospitals not accredited by the Joint Commission.
Why would the reports of the National Quality Improvement Goals and the Hospital Quality Alliance be different on the Joint Commission and CMS websites?
Although the Joint Commission and CMS are working together to align their measurement activities, reports may be different because:
- The Hospital Quality Alliance database includes hospitals unaccredited by the Joint Commission.
- The Joint Commission database includes hospitals that are not part of the Hospital Quality Alliance, for example, Department of Defense hospitals.
- The Joint Commission minimum time frames for initial reporting are greater than those of CMS.
- The Joint Commission accepts retransmission of data to correct data submitted within the seven previous quarters. CMS does not accept retransmissions to correct data submitted for previous quarters.
- There may be multiple Joint Commission IDs for a single CMS provider ID.
Still to come
The Quality Report will evolve over time. As more measures are approved and endorsed by the NQF, the Joint Commission will explore ways to incorporate that data into Quality Reports. The Joint Commission will continue to align its measure requirements with the Hospital Quality Alliance and its measure specifications with CMS. Your organization may e-mail questions or comments about Quality Reports to qualityreport@jointcommission.org.