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Thursday 12:46 CST, February 22, 2018

Joint Commission FAQ Page

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Top Performer on Joint Commission Key Quality Measures - Submit a Question

What is the Joint Commission's Top Performer on Key Quality Measures® program?

Why did The Joint Commission launch this program?

When did The Joint Commission launch its Top Performer recognition program?

What eligibility criteria are used to determine if an organization is a Top Performer?

How does the Top Performer on Key Quality Measures program work?

Do hospitals need to submit an application to be considered for the Top Performer on Key Quality Measures program?

My hospital collects additional core measure sets beyond those of the ORYX requirements; will the accountability measures in these additional sets be included in the calculation of my hospital’s composite score for potential Top Performer recognition?

What does it mean if a hospital is not on the list?

How many hospitals are being recognized on the Top Performer list and what are the demographics?

What is new for the Top Performer on Key Quality Measures program?

Why are you announcing Top Performer hospitals now, when the data are from care delivered in the previous calendar year?

My hospital was at 95 percent on all the measures in a particular set, yet we didn’t get recognized. How could that happen?

Who do I contact if I have a question about our organization’s data?

Who do I contact if I have a question about publicizing this accomplishment?

What determines if a hospital is “on track” to being a Top Performer?

How can those organizations that did not make the list improve their performance?

What is an accountability measure?

Psychiatric hospitals have been reporting inpatient psychiatric services measures for some time. Are these hospitals eligible for the Top Performer designation?

What about rehabilitation hospitals?

Are the multiple antipsychotic medications measures (HBIPS-4a and HBIPS-5a) included in the composite for the inpatient psychiatric services measure set?

What is the time frame covered for “seasonal” measures included in the calculations for Top Performer recognition?

Why are the HBIPS-2 and HBIPS-3 measures excluded from the Top Performer program?

How are measures, where a decrease in measure rate is desirable, handled in the eligibility criteria calculations?

Why are some well-known hospitals and academic medical centers recognized on other lists and not on the Top Performer list?

How is the Top Performer program different from other hospital recognition and award programs?

Our hospital is a Top Performer, but our name is not displayed correctly on our certificate. Why is it incorrect?

Our Top Performer notification package was not directed to our current CEO. Why was the contact information incorrect?

We received a corporate notification listing the hospitals within our system that attained Top Performer status, but some hospitals were missing. Why were hospitals missing, and how can we get that information corrected?

Can we use our hospital’s ORYX Performance Measurement Report (PMR) to determine our Top Performer composite rate?

Why might there be a difference in the number of Top Performer hospitals noted in the annual report and the list in the appendix?

When will the announcement of Top Performer hospitals be in 2015 (for 2014 data)?

Will there be a Joint Commission Top Performer on Key Quality Measures® program in 2016 (based on 2015 data)?


Top Performer on Joint Commission Key Quality Measures

Q: What is the Joint Commission's Top Performer on Key Quality Measures® program?
A:

The Joint Commission’s Top Performer 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 ORYX® accountability measure data reported to The Joint Commission during the previous calendar year. The data report on evidence-based interventions for heart attack, heart failure, pneumonia, surgical care, children’s asthma care, hospital-based inpatient psychiatric services, venous thromboembolism (VTE), stroke, immunization, perinatal care, substance use, and tobacco treatment.

 

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Q: Why did The Joint Commission launch this program?
A:

Excellent care is something all patients expect and deserve. Hospitals work hard to achieve it. However, 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, improve their performance on key measures, and identify target areas for improvement, The Joint Commission launched the Top Performer on Key Quality Measures program in 2011. This program honors hospitals that demonstrate excellent performance on evidence-based process of care measures. Also, it 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 ultimate goal is to improve the care provided to patients in all aspects addressed by these accountability measures.

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Q: When did The Joint Commission launch its Top Performer recognition program?
A:

The program launched in September 2011. Recognition of Top Performer hospitals occurs in the fall of each year and coincides with the publication of The Joint Commission’s “America’s Hospital’s: Improving Quality and Safety annual report. 

 

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Q: What eligibility criteria are used to determine if an organization is a Top Performer?
A:

The current eligibility criteria for the Top Performer program include a three step process: 1) achieving cumulative performance of 95 percent or above across all reported accountability measures; 2) achieving performance of 95 percent or above on each and every reported accountability measure where there are at least 30 denominator cases; and 3) having at least one core measure set that has a composite rate of 95 percent or above, and within that measure set all applicable accountability measures have a performance rate of 95 percent or above. See the eligibility criteria.

 

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Q: How does the Top Performer on Key Quality Measures program work?
A:
  • Inclusion on the list is based on an aggregation of ORYX® accountability measure data reported to The Joint Commission during the previous calendar year.

  • A Top Performer must meet the eligibility criteria (also see question above).

  • Top Performer hospitals receive a certificate of recognition, a notification letter from Joint Commission President and CEO, Dr. Mark R. Chassin, and are recognized on The Joint Commission’s Quality Check website and in the “America’s Hospital’s: Improving Quality and Safety” annual report. (A copy of the certificate of recognition and notification letter are provided on the hospital’s Joint Commission Connect extranet.)

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

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Q: Do hospitals need to submit an application to be considered for the Top Performer on Key Quality Measures program?
A:

No, hospitals are not required to apply for the program; eligibility is determined using data that hospitals already transmit to The Joint Commission through the ORYX® program. Critical access hospitals that 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 calendar year’s ORYX data.

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Q: My hospital collects additional core measure sets beyond those of the ORYX requirements; will the accountability measures in these additional sets be included in the calculation of my hospital’s composite score for potential Top Performer recognition?
A:

Yes, all accountability measures/measure sets that have been included as part of the Top Performer program for a given calendar year and that are reported by your organization for the full 12 months of that year will be included in determining if your hospital meets the three performance criteria for Top Performer hospitals. See the current list of accountability measures that were used for the Top Performer program.

 

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Q: What does it mean if a hospital is not on the list?
A:

Most hospitals not recognized as a Top Performer are still performing well on accountability measures, but there is still room for improvement. Since 2002, hospitals have been reporting data to The Joint Commission and have continuously shown improvement in performance on core measures. The Top Performer program supports organizations in their quest to do better.

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Q: How many hospitals are being recognized on the Top Performer list and what are the demographics?
A:

In 2015, 1,043 hospitals are being honored for their performance on 2014 calendar year discharge data as part of the Top Performer on Key Quality Measures program. Of that number, 27 percent were rural hospitals, 55 percent were non-profit hospitals, 42 percent and had between 100 and 300 beds. Major teaching hospitals accounted for 6 percent of the recipients, and 7 percent were critical access hospitals.

 

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Q: What is new for the Top Performer on Key Quality Measures program?
A:
  • For the first time in 2014, acute care hospitals were required to meet program criteria in six sets – an increase from four sets.

  • Two new measure sets – tobacco treatment and substance use – were added to the program for the first time with 2014 data. Both new measure sets consist of three accountability measures and were used in the calculation of the composite accountability measures.

  • Formerly a test measure, admissions screening in the inpatient psychiatric services measure set is now an accountability measure and was included in the calculation of the composite accountability measures.

  • Two perinatal care measures will be used, rather than three for calculation for the 2015 program (based on data submitted in 2014). Exclusive breast milk feeding considering mother’s choice (PC-05a) was retired effective with 10/1/2015 discharges and will not be included in The Joint Commission’s calculation of composite rates for 2014. See the current list of accountability measures used for the Top Performer program. 

  • A group of 23 Top Performer hospitals exceeded expectations by collecting and reporting data on seven or more core measure sets – more than the required number of six sets.

 

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Q: Why are you announcing Top Performer hospitals now, when the data are from care delivered in the previous calendar year?
A:

There is approximately a four to six month delay between the time the hospital collects and submits their data to the performance measurement system to the time it is received by The Joint Commission.

 

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Q: My hospital was at 95 percent on all the measures in a particular set, yet we didn’t get recognized. How could that happen?
A:

There may be one or more reasons for this. Although your hospital may have 95 percent in a particular measure set, it may have:

  • Failed to achieve 95 percent on the composite score for all accountability measures.

  • Failed to achieve 95 percent on each and every reported accountability measure in that measure set.

  • Failed to collect data for four calendar quarters for all measures within that set (except for seasonal measures, which require only two quarters of collected data), or had fewer than 30 total cases for the measures associated with that particular set.

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Q: Who do I contact if I have a question about our organization’s data?
A:

First, we encourage hospitals to contact their ORYX vendor. You may also send an e-mail to topperformersprogram@jointcommission.org.

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Q: Who do I contact if I have a question about publicizing this accomplishment?
A:

For all Top Performer publicity questions, send an email to tppublicitykit@jointcommission.org.

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Q: What determines if a hospital is “on track” to being a Top Performer?
A:

Hospitals that are “on track” to becoming a Top Performer have achieved the 95 percent composite score and 95 percent performance on all but one accountability measure for which it reports data. After Top Performer hospitals are announced, The Joint Commission notifies “on track” hospitals about the measure on which they need to improve performance should they wish to achieve Top Performer recognition in the future. This notification is made via the hospital’s Joint Commission Connect extranet within the Top Performer Section.

 

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Q: How can those organizations that did not make the list improve their performance?
A:

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 Solution 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 Solution 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 organization’s account executive or accreditation liaison. 

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Q: What is an accountability measure?
A:

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.  The Joint Commission has a primary focus on adopting accountability measures for its ORYX program. For more information, see Facts about accountability measures and the current list of accountability measures used for the Top Performer program. 

 

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Q: Psychiatric hospitals have been reporting inpatient psychiatric services measures for some time. Are these hospitals eligible for the Top Performer designation?
A:

In 2012, freestanding psychiatric hospitals or hospitals with inpatient psychiatric units were included in the Top Performer program for the first time, based on 2011 calendar year data. 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.

 

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Q: What about rehabilitation hospitals?
A:

Rehabilitation hospitals are not eligible for Top Performer designation at this time. Currently, rehabilitation hospitals do not submit core accountability measure data. Effective January 1, 2013, The Joint Commission suspended 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).

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Q: Are the multiple antipsychotic medications measures (HBIPS-4a and HBIPS-5a) included in the composite for the inpatient psychiatric services measure set?
A:

HBIPS-4a (multiple antipsychotic medications) is not be included in The Joint Commission’s calculation of composite rates. However, HBIPS-5a (justification for multiple antipsychotic medications) is included in The Joint Commission’s calculation of composite rates for the 2015 program (based on calendar year 2014 data).

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Q: What is the time frame covered for “seasonal” measures included in the calculations for Top Performer recognition?
A:

Seasonal measures, such as immunizations, are included if two quarters of data exist for the calendar year under consideration. For example, for the influenza immunization measure (IMM-2), 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). 

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Q: Why are the HBIPS-2 and HBIPS-3 measures excluded from the Top Performer program?
A:

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., Top Performer calculations only include process measures reported as proportions). The current statistical model used to calculate the composite rate does not accommodate ratios. 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.

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Q: How are measures, where a decrease in measure rate is desirable, handled in the eligibility criteria calculations?
A:

For most measures, improvement will be indicated by an increase in the measure rate. However, there are some measures where improvement will be indicated by a decrease in the rate. In calculating the accountability composite, it is important that the direction of improvement for all the individual measures be in the same direction. For those measures where a decrease in the rate is desired (e.g., elective delivery (PC-01)), the number of denominator cases minus the number of numerator cases for the measure will be used in the eligibility criteria calculations in place of the original number of numerator cases. This will allow a measure where a decrease in the rate is desired to be transformed into a measure similar to the majority of accountability measures where an increase in the rate is desired.   

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Q: Why are some well-known hospitals and academic medical centers recognized on other lists and not on the Top Performer list?
A:

Other national recognition programs or hospital comparisons may use other measures, metrics, or data, or rely on a hospital’s reputation as a determination of achievement. The Top Performer program uses evidence-based performance measures that have undergone rigorous development and testing to ensure data integrity. This year, the number of academic medical centers recognized as Top Performer hospitals decreased from a 2014 peak: in 2011 and 2012 there were five; in 2013, 26 academic medical centers were included in the list of Top Performer hospitals; 35 for 2014; and in 2015 there are 28.


 

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Q: How is the Top Performer program different from other hospital recognition and award programs?
A:

The Top Performer program is unique from other recognition programs in that it is based completely on objective data. This enables each hospital to track its measure performance and predict whether it will be a Top Performer.

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Q: Our hospital is a Top Performer, but our name is not displayed correctly on our certificate. Why is it incorrect?
A:

As hospitals were informed via Perspectives and Joint Commission Online articles in 2015, The Joint Commission uses the hospital’s legal name as denoted within eApp for the certificates and the Annual Report listing. It is possible that your hospital has not correctly entered or updated your hospital’s name.

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Q: Our Top Performer notification package was not directed to our current CEO. Why was the contact information incorrect?
A:

As referenced above, articles in 2015 in Perspectives and Joint Commission Online denoted to hospitals that the contact information current displayed for the CEO within eApp is directly used to address and send the email notification and the mailed package with the Top Performer certificate for each hospital. It is possible that if the CEO has changed, that the contact information entered by your facility is incorrect or not current and should be updated.

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Q: We received a corporate notification listing the hospitals within our system that attained Top Performer status, but some hospitals were missing. Why were hospitals missing, and how can we get that information corrected?
A:

In Perspectives and Joint Commission Online articles in 2015, The Joint Commission advised hospitals that the eApp records should contain the correct ownership information so that when grouping hospitals to a corporate entity, the Ownership field in eApp can be utilized. It is possible that some of your hospitals do not have this affiliation denoted within their eApp records. To get the information corrected, contact your hospitals directly and request that they contact their Joint Commission account representative to make needed corrections. A new certificate can be requested through topperformersprogram@jointcommission.org after the corrections are verified within eApp for these hospitals. It is also possible that some hospitals within the system did not achieve Top Performer status. Only those hospitals that achieved Top Performer status are denoted on the Top Performer corporate certificates.

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Q: Can we use our hospital’s ORYX Performance Measurement Report (PMR) to determine our Top Performer composite rate?
A:

No. The accountability composite displayed on the ORYX Performance Measure Report is based on a rolling four calendar quarters of data, while the composite rate used to identify those hospitals qualifying as a Top Performer is based on data for a calendar year, e.g. 2015 Top Performer hospitals are identified based on data for CY 2014.  

 

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Q: Why might there be a difference in the number of Top Performer hospitals noted in the annual report and the list in the appendix?
A:

The list that is published within the Annual Report reflects only those hospitals that are currently accredited by The Joint Commission. Due to market forces, some hospitals are acquired or merge in the interim.
 

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Q: When will the announcement of Top Performer hospitals be in 2015 (for 2014 data)?
A:

The Joint Commission will announce the 2015 recipients of the Top Performer on Key Quality Measures® recognition to national, trade and consumer media (including regional outlets) on November 17, 2015 during a telephone press conference held in conjunction with the release of the Joint Commission’s annual report. If you are a Top Performer hospital, a package will be sent to your hospital’s Chief Executive Officer by November 9, 2015 by way of UPS ground, and will include a congratulatory letter, a certificate of recognition, and publicity information. The receipt of this package will stand as the hospital’s official notification.
 

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Q: Will there be a Joint Commission Top Performer on Key Quality Measures® program in 2016 (based on 2015 data)?
A:

No, The Joint Commission will place the current Top Performer program on hiatus for a year to be reevaluated. The last two years have seen many changes in performance measurement. The Centers for Medicare and Medicaid Services (CMS) has made significant changes to the performance measures in the Hospital Inpatient Quality Reporting Program,including retiring a number of chart-based measures. The Joint Commission made many of these same changes to maintain alignment with CMS, and we introduced the Flexible Reporting Option in 2015 to respond to our customers' requests that they be allowed to choose which measure sets to report. The Flexible Reporting Option also allowed hospitals to begin reporting electronic clinical quality measures (eCQMs). The push for eCQMs will accelerate in 2016 when CMS will implement a requirement for hospitals to report at least four eCQMs.
 
The Joint Commission's Top Performer program has utilized the results of a fixed set of designated accountability chart-based performance measures to compare performance and determine top hospitals. But now, the retirement of some accountability measures, the heterogeneity of measure sets reported by hospitals, and the fact that performance rates for eCQMs may not be equivalent to performance rates on chart-based measures make it very difficult to compare hospitals and identify Top Performer hospitals. 

For these reasons, the Top Performer program, in its current form, will take a pause for 2016 while The Joint Commission reevaluates the program to better fit the evolving national measurement environment. The Joint Commission remains committed to measures that meet our accountability criteria, which greatly increase the likelihood that patient outcomes will improve if hospitals achieve increased performance on the measures we include in the Top Performer program.

In the interim, The Joint Commission will provide a program that continues to support our Top Performer hospitals, as well as those hospitals moving towards becoming a Top Performer. The details of this new program will be forthcoming.

 

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