The Joint Commission’s Top Performers on Key Quality Measures program recognizes accredited hospitals that attain excellence in accountability measure performance. Recognition in the program is based on an aggregation of accountability measure data reported to The Joint Commission during the previous calendar year. This year’s recognition program is based on data that were reported for 2011. The data report on evidence-based clinical processes that are shown to be the best treatments for certain conditions, including heart attack, heart failure, pneumonia, surgical care, children’s asthma care, inpatient psychiatric services, venous thromboembolism (VTE), and stroke.

 As follows:

• Inclusion on the list is based on an aggregation of accountability measure data reported to The Joint Commission during the previous calendar year. For example, this year’s program is based on data that were reported for 2011.  

• Top Performers must first achieve performance of 95 percent or above on a single, composite score that includes all the accountability measures for which it reports data to The Joint Commission, including measures that had fewer than 30 eligible cases or patients. Second, the hospital also must meet a 95 percent performance target for every accountability measure for which it reports data to The Joint Commission, excluding any measures with less than 30 eligible cases or patients. For more information, see the section below on eligibility criteria.

• Top Performers are notified of their recognition approximately one week before the publication of The Joint Commission’s annual report.

• Top Performers receive a certificate of recognition and are recognized on The Joint Commission’s Quality Check website, and in the “Improving America’s Hospitals” annual report.
   

The following is the specific eligibility criteria for Joint Commission-accredited hospitals reporting data during 2011 on one or more core measure sets with accountability measures. There are two levels of evaluation criteria: the first for recognition designation; and the second for individual core measure set designation.

Eligibility criteria for recognition designation (both criteria must be met)

Criteria 1: Reported accountability measure composite rate is greater than or equal to 95 percent.
Divide the sum of all the reported accountability measure numerators by the sum of all the reported accountability measure denominators. This calculation must meet or exceed 95 percent.

• The sum of all the reported accountability measure denominators must be equal to or greater than 30 for this criterion to be met.
• Measures reported for less than 12 months during 2011 (less than six months for the pneumonia set influenza measure) are excluded from this calculation.
• Measures with denominators of less than 30 cases are included in this calculation.

Criteria 2: Reported accountability measure rates for each individual measure are greater than or equal to 95 percent.
For each individual reported accountability measure, divide the numerator by the denominator. Each of these calculations must meet or exceed 95 percent.

• Measures with denominators of less than 30 cases are not considered when determining whether this criterion is met.
• Measures reported for less than 12 months during 2011 (less than six months for the pneumonia set influenza measure) are not considered when determining whether this criterion is met.
• If all the reported accountability measures have denominators less than 30, then the organization is not eligible to be listed.

Eligibility criteria for individual core measure set designation (both criteria must be met for each core measure set to be independently considered)

Criteria 1: Reported composite rate for all accountability measures within a particular core measure set is greater than or equal to 95 percent.
Using only the accountability measures within a particular measure set, divide the sum of all the reported numerators by the sum of all the reported denominators. This calculation must meet or exceed 95 percent.

• If the sum of the denominators for the accountability measures in the set is less than 30, then the organization is not eligible to have this core measure set listed.
• Measures reported for less than 12 months during 2011 (less than six months for the pneumonia set influenza measure) are not considered when determining whether this criterion is met.
• Measures with denominators of less than 30 cases are included in this calculation.

Criteria 2: Reported accountability measure rates for each individual measure within the core measure set are greater than or equal to 95 percent.
For each individual reported accountability measure within a particular core measure set, divide the numerator by the denominator. Each of these calculations must meet or exceed 95 percent.

• Measures with denominators of less than 30 cases are not considered when determining whether this criterion is met.
• Measures reported for less than 12 months during 2011 (less than six months for the pneumonia set influenza measure) are not considered when determining whether this criterion is met.
• If all the reported accountability measures within a particular measure set have denominators less than 30, then the organization is not eligible to have this core measure set listed.

No, hospitals are not required to send in an application. Eligibility is determined using data that hospitals already transmit to The Joint Commission through the ORYX® program. Critical access hospitals that elect to report accountability measure data to The Joint Commission are also eligible. Recognition as a Top Performer is based on the total number of accountability measures reported by each hospital, regardless of whether the hospital transmits data on one measure set or several measure sets. Also, each year’s recipients are identified using the previous year’s ORYX data. The recipients honored in 2012 were selected based on data they submitted for 2011.
 

• Most hospitals not recognized as Top Performers are still performing well on accountability measures, but there is still room for improvement.
• The Joint Commission provides various resources to help hospitals improve their accountability measure performance, including the Core Measure Solution Exchange and the Leading Practices Library. Both of these resources are available on The Joint Commission Connect extranet site.
• Since 2002, hospitals have been reporting data to The Joint Commission and have continuously shown improvement on core measures. The Top Performers program supports organizations in their quest to do better.
   

This year (which is 2012, but is for data submitted in calendar year 2011), 620 hospitals are being honored as Top Performers on Key Quality Measures. Of that number, 26 percent are rural hospitals, 45 percent are non-profit hospitals, and 49 percent have between 100 and 300 beds. Major teaching hospitals account for 5 percent of the recipients, and 5 percent are critical access hospitals.
 

The program launched in September 2011. Recognition of Top Performers occurs in the fall of each year and coincides with the publication of The Joint Commission’s “Improving America’s Hospitals” annual report. 
 

There may be one or more reasons for this. Although you may have 95 percent in a particular measure set, you may have failed to achieve 95 percent on the composite; or, you may have failed to achieve 95 percent on each and every reported accountability measure in the measure set.
 

You may have failed to collect data for four calendar quarters for the measures within that particular measure set; or, you may have had fewer than 30 total cases for the measures associated with that particular set.
 

Excellent care is something all patients expect and deserve and all hospitals work to achieve. It is not an easy goal to reach; it takes the knowledge, teamwork and dedication of the entire hospital staff. To help hospitals achieve this goal, The Joint Commission has undertaken a multifaceted accountability measures initiative that seeks to enhance patient care by helping hospitals improve their performance on key measures and identify target areas for improvement. The Joint Commission launched this initiative – the Top Performers on Key Quality Measures program – to honor those hospitals that consistently demonstrate excellent performance on evidence-based process of care measures. This program is intended to encourage hospitals to consistently improve their performance on accountability measures by publicly recognizing those that ultimately achieve excellence in this arena.
 

The Joint Commission has taken many steps to help hospitals improve their performance on accountability measures, including integrating accountability measures into the accreditation standards (effective January 1, 2012), redesigning the ORYX performance measure reports, and making changes to the S3 program and the Priority Focus Process. Also, in April 2011, The Joint Commission launched its Core Measure Solution Exchange™, a web-based platform where accredited organizations can share practices and proven tools related to improving performance on core measures. The Exchange is an interactive forum designed to facilitate peer-to-peer communication. For organizations that have worked to improve their core measure performance, it is an opportunity to share their success and be recognized for their accomplishments. For organizations looking to improve, it is an opportunity to see what their peers have tried and what has actually worked. The Exchange is available via your organization’s Joint Commission Connect extranet under Quality Improvement Tools. If you need access to your organization’s Connect extranet, talk to your accreditation account executive or your organization’s accreditation liaison.
 

There is typically a six month delay from the time the hospital collects and submits the data to the performance measurement system and it is then received by The Joint Commission.
 

This year, freestanding psychiatric hospitals or hospitals with inpatient psychiatric units are being recognized as Top Performers for the first time. Reporting on the inpatient psychiatric services measure set was not required until January 2011, so 2011 was the first year that these data became available for the Top Performer program designation.
 

Rehabilitation hospitals are not eligible for Top Performer designation at this time. Currently, rehabilitation hospitals do not submit data on core measures, which include measures designated as accountability measures. Rather, they submit data on what are known as non-core measures. However, effective January 1, 2013, The Joint Commission will suspend ORYX performance measure reporting requirements for accredited inpatient rehabilitation facilities (IRFs). It is The Joint Commission’s intent to support and build upon the emerging national measurement priorities and the move to the use of standardized federally mandated performance measures for IRFs (when those measures are identified and implemented).
 

For the multiple antipsychotic medications measure (HBIPS-4), improvement is indicated by a decrease in the rate. In calculating the accountability composite, it is important that all of the individual measures indicate improvement in the same direction. For this measure, where a decrease in the rate is desired, the number of denominator cases minus the number of numerator cases will be used in the accountability composite. This converts the rate so that it can be used in the composite with the majority of accountability measures where an increase in the rate is desired.
 

Seasonal measures, such as immunizations, are included if two calendar quarters of data exist for the calendar year under consideration. For example, for the influenza vaccination measure (PN-7), the denominator includes patients discharged during October, November, December, January, February, or March. The quarters that would have to exist within the calendar year would be both the first quarter (January, February, and March) and the fourth quarter (October, November, and December). 
 

First, we encourage you to contact your performance measurement system. You may also send an e-mail to topperformersprogram@jointcommission.org or call (630) 792-5085.
 

The Top Performers program uses evidence-based performance measures that have undergone rigorous development and testing to ensure data integrity. These measures cover eight conditions: heart attack, heart failure, pneumonia, surgical care, children’s asthma, inpatient psychiatric services, venous thromboembolism (VTE), and stroke. Other recognition programs or hospital comparisons may use other measures, metrics, or data, or rely on a hospital’s reputation as a determination of achievement. 

In 2010, The Joint Commission began categorizing its process performance measures into accountability and non-accountability measures. The approach places more emphasis on an organization’s performance on accountability measures – quality measures that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement: research, proximity, accuracy and adverse effects. Non-accountability measures are suitable for secondary uses, such as exploration or learning within individual health care organizations, and are good advice in terms of appropriate patient care. Going forward, The Joint Commission is only adopting accountability measures for its ORYX program. For more information, see Facts about accountability measures.  
 

The heart attack care core measure set started out at a relatively higher rate than other measure sets. This may be best described as a ceiling effect, with improvement more challenging for some organizations because of the already high rate.
 

Although the physical restraint (HBIPS-2) and seclusion (HBIPS-3) measures in the inpatient psychiatric services measure set are accountability measures, they have been excluded from the Top Performer calculation since they are both ratio measures (i.e., calculations only include process measures reported as proportions). Ratio measures do not reflect the number of people (as for proportion measures), but rather the number of psychiatric inpatient days. The number of inpatient days in the denominator is usually a large number, so including it in the composite would unduly weight the composite toward ratio measures.

Additionally, the multiple antipsychotic medication measure (HBIPS-4) is a measure where a decrease in the rate is the desirable direction of improvement; therefore, this measure is included in the Top Performer calculation by using the denominator of the measure minus the numerator (rather than using the numerator).
 

Since 20 new measures were added to the Top Performers program this year, many of the hospitals that were Top Performers last year missed the performance threshold on one or more of these new measures. Of the 162 hospitals that were Top Performers last year but not this year, 87 were part of the 583 hospitals that missed Top Performer status by one measure.  
 

We involved our customers, unaccredited providers, payers, and hospital referral sources in the overall redesign process.  Customers provided feedback on standards through online surveys and participated in pilot on-site surveys.  Additionally, focused calls were conducted with select customers to gain in-depth perspective on proposed program enhancements. 

This year, there are 290 for profit hospitals, 279 not-for-profit hospitals, and 51 government hospitals recognized as Top Performers. Since the inception of the Top Performers program in 2011, more for-profit hospitals than not-for-profit hospitals have been recognized as Top Performers.

Three accountability measure sets were added in the calculation for this year’s Top Performers program – inpatient psychiatric services, stroke and venous throboembolism (VTE).