Guidelines for Publicizing Hospital National Quality Improvement Goals | Joint Commission

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Tuesday 4:39 CST, May 22, 2018

Guidelines for Publicizing Hospital NQIGs


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, children’s asthma, pneumonia, and surgical care. 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:

  • Patient receives aspirin when arriving at the hospital.

  • Assure that the patient receives a prescription for aspirin at discharge.

  • Give the patient a prescription for a beta blocker at discharge.

  • Provide the patient with fibrinolytic therapy within 30 Minutes of arrival to the hospital.

  • Assure that the patient receive primary PCI treatment within 90 minutes of arrival to the hospital.

  • For patient with LVSD (left ventricular systolic dysfunction) provide a prescription at discharge for an ACE Inhibitor or ARB.

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."
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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.


  • 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.

  • 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 Centers for Medicare and Medicaid Services

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 on Hospital Compare which is a consumer-oriented website that provides information on how well hospitals provide recommended care to their patients.

Why would the reports of the National Quality Improvement Goals on the Joint Commission websites and the reports from the Hospital Inpatient Quality Reporting Program on the CMS Websites be different?

Although the Joint Commission and CMS are working together to align their measurement activities, reports may be different because:

  • The CMS website, Hospital Compare, includes hospitals that are not accredited by the Joint Commission.

  • The Joint Commission database includes hospitals that are not part of the Hospital Inpatient Quality Reporting Program, 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 up to seven previous quarters. CMS does not accept retransmissions of data.

  • The Joint Commission’s Quality Check website uses accountability measures to calculate the overall performance rate for each measure set. Accountability measures are quality measures that meet four criteria (research, proximity, accuracy and adverse effects) designed to identify measures that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement. Hospital Compare uses some measures that The Joint Commission has categorized as non-accountability measures.

The Quality Report will evolve over time. As more measures are approved and endorsed by the National Quality Forum (NQF), the Joint Commission will explore ways to incorporate that data into Quality Reports. When is possible, The Joint Commission will continue to align its measure specifications with CMS. Your organization may e-mail questions or comments about Quality Reports to