Facts about The Joint Commission’s Top Performers on Key Quality Measures program | Joint Commission
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Facts about Top Performer on Key Quality Measures® Program

October 29, 2015

Launched in September 2011, The Joint Commission’s Top Performer on Key Quality Measures®* program recognizes accredited hospitals that attain excellence on accountability measure performance. The program is based on data reported about evidence-based care processes for certain conditions, including heart attack, heart failure, pneumonia, surgical care, children’s asthma, inpatient psychiatric services, venous thromboembolism, stroke, perinatal care, immunization, tobacco treatment and substance use. The recognition 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. The Top Performer on Key Quality Measures program is:

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

  • An incentive for all hospitals to improve and be the best they can be through attaining high rates of performance on all the accountability measures for which a hospital reports data.

  • Consistent with the current themes of the pay-for-performance trends being enacted by federal and state governments and many private payers.

  • A way to provide transparency to the public in the reporting of performance at the hospitals where they receive care.

Top Performer program to take 2016 off for reevaluation

The Joint Commission’s Top Performer program will take a hiatus for 2016 in order to reevaluate the program to better fit the evolving national measure environment. The Top Performer program has utilized the results of a fixed set of designated accountability chart-based performance measures to compare performance and determine Top Performer hospitals. But now, the retirement of some accountability measures, the heterogeneity of measure sets reported by hospitals, and the fact that performance rates for electronic clinical quality measures (eCQMs) may not be equivalent to performance rates on chart-based measures make it very difficult to compare hospitals and identify Top Performer hospitals.

The Joint Commission plans to provide a program that continues to support its Top Performers, as well as those hospitals moving toward becoming a Top Performer. During the hiatus year, hospitals will continue to collect and submit data. 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.

How the program works

  • Inclusion on the list is based on an aggregation of accountability measure data reported to The Joint Commission during the previous calendar year. The Top Performer hospitals announced in 2015 are selected based on data that were reported for 2014.  

  • A recognized hospital must meet three performance criteria based on accountability data: 1) achieve cumulative performance of 95 percent or above across all reported accountability measures; 2) achieve performance of 95 percent or above on each and every reported accountability measure where there are at least 30 denominator cases; and 3) have at least one core measure set that has a composite rate of   95 percent or above, and (within that measure set) all applicable individual accountability measures have a performance rate of 95 percent or above.

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

  • Recognized hospitals receive: a congratulatory letter from Joint Commission President and Chief Executive Officer Mark R. Chassin, MD, FACP, MPP, MPH; a certificate of recognition; a communications toolkit; acknowledgement on The Joint Commission website and on The Joint Commission’s Quality Check website, as well as in the America’s Hospitals: Improving Quality and Safety annual report.

Read more about the Top Performer on Key Quality Measures® program

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*Being named a Top Performer by The Joint Commission does not ensure that any specific patient in such a named hospital will have any particular medical outcome. Nor is Top Performer status a reflection of the overall care at an organization. Top Performer recognition is based on hospital performance on measures specific to performance measurement during a specific period of time in certain patient care areas, but not all the patient care areas provided by acute care hospitals.