Individuals may freely download hospital-specific performance measurement data from the Joint Commission’s Quality Check website.
The performance measurement data is organized into core measure sets, each of which relates to a condition of care. The core measure sets included in the download are acute myocardial infarction (AMI), heart failure (HF), pneumonia (PN), pregnancy (PR), and surgical infection prevention (SIP). Hospitals are required to pick a subset of these measure sets to report to the Joint Commission. Currently hospitals are required to pick a minimum of three measure sets and submit data for all the measures within a measure set. Hospitals submit data to an intermediary called a performance measurement system. The measurement system aggregates a hospital’s data and sends this aggregated data to the Joint Commission quarterly. The Joint Commission then aggregates this quarterly data over the last four reported quarters for reporting on Quality Check.
The Joint Commission uses two types of measures to report National Quality Improvement Goal results: process measures and outcome measures.
Process measures describe how often a series of recommended activities, actions, or steps are done (for example, a treatment such as aspirin at arrival) in a patient population over a set time period. Process measures are expressed in terms of a percentage, or rate. The denominator is the total number of patients for whom the treatment or event was recommended.
Outcome measures describe the end results of a function or process in a patient population over a set period of time. Outcome measures are expressed in terms of a percentage or rate. The denominator is the total number of patients at risk for the outcome.
Included in the download is the following:
- Hospital Results - Symbol
The symbol represents the comparison of the hospitals performance for the measure to the national average at the measure and measure set level.
- Hospital Results – Number
The number of times as a percentage the hospital performed the measure during the time period being reported.
- Total Patients
The total number of patients treated for the measure.
- Nationwide - Average Rate
The average rate for all Joint Commission accredited healthcare organizations in the nation that provide results for a measure. The average rate is calculated by dividing the total number of patients who had the recommended care provided for a measure by the total number of patients who met the inclusion and exclusion criteria for that measure in the timeframe being reported.
- Nationwide - Top 10%
Scored at Least: The number of times, as a percentage, the top 10% of all Joint Commission accredited hospitals in the nation followed the recommended treatment/ procedure during the time period being reported.
- Statewide - Average Rate
The average rate for all Joint Commission accredited healthcare organizations in the state that provide results for a measure. The average rate is calculated by dividing the total number of patients who had the recommended care provided for a measure by the total number of patients who met the inclusion and exclusion criteria for that measure in the state for the timeframe being reported.
- Statewide - Top 10%
Scored at Least: The number of times, as a percentage, the top 10% of all Joint Commission accredited hospitals in the state followed the recommended treatment/procedure during the time period being reported.
Uses of Quality Check Data
Quality Check data includes national rates, state rates, and hospital rates at the measure level. Data may be analyzed in many ways. Comparisons may be made from the hospital to national/state level. Comparisons between hospitals may be made. Hospitals with known similar characteristics may have their rates combined and compared to various benchmarks, either provided by the Joint Commission data download or to an outside credible source. Valid comparisons must be consistent using the same measures.
Misuses of Quality Check Data
Proper care needs to be taken into consideration when analyzing Quality Check data. Analysis of the data should incorporate the proper distribution of the data. Some analysis may require the use of a Binomial Distribution, Chi-Square Distribution, or Normal Distribution. Using a wrong distribution will yield incorrect inferences about a hospital’s level of care. Another source of error is to use different measures in making comparisons from one hospital to another. Process measures should be compared with process measures and not to outcomes measures.