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The Joint Commission begins public reporting for two hospital perinatal care measures in 2021

Cesarean birth rates and unexpected newborn complications made public Monday, February 01 2021

Maureen Lyons
Corporate Communications

(OAKBROOK TERRACE, Illinois, February 1, 2021) – The Joint Commission today began publicly reporting hospital performance on two ORYX® perinatal care measures: one that measures cesarean birth rates, (PC-02); and another that measures unexpected complications in term newborns, (PC-06). Joint Commission-accredited hospitals’ performances on these two measures are reported on the Quality Check® website. Reporting this data is consistent with The Joint Commission’s long-standing commitment to provide meaningful information about the performance of accredited organizations to the public.

The Cesarean Birth measure, PC-02, measures the rates of cesarean births among a subset of the general obstetric population of low-risk women having their first birth (Nulliparous) with a Term, Singleton baby in a Vertex (head down) position (NTSV). The Joint Commission is using data reported by hospitals during 2018 and 2019, along with the following three criteria, to determine a hospital’s PC-02 rating: 

  1. Greater than or equal to 30 cases reported during both years 
  2. PC-02 rate measures greater than 30% for 2019 
  3. Overall aggregate PC-02 rate for 2018-19 is greater than 30%*

On Quality Check®, hospitals are identified with either a plus (+) or minus (-) symbol indicating that each facility’s rate is either acceptable (+) or unacceptable (-). A plus (+) symbol signifies that a hospital has an acceptable rate and a minus (-) symbol signifies that a hospital’s cesarean rate is consistently high (and has a large enough sample size to make this determination). 

“We are excited to be moving forward with our mission to improve the health of expectant mothers and their infants by working to reduce the consistently high rate of cesarean sections that we see at many hospitals,” says David W. Baker, MD, MPH, FACP, executive vice president for Health Care Quality Evaluation, The Joint Commission. “By identifying hospitals with consistently high cesarean rates, The Joint Commission aims to encourage leaders to work with us to safely reduce their rates.”

In March 2020, The Joint Commission delayed its initial implementation of the public reporting due to the impact of COVID-19 on hospitals. However, 2019 fourth quarter data analysis showed that most hospitals continued to submit data for the ORYX® measures, which allowed reporting plans to resume.

To reduce the burden on hospitals challenged by the pandemic, submitting fourth quarter 2019 data was made optional in March 2020. As a result, some hospitals did not submit fourth quarter 2019 data and may not yet be included in the public reporting.

The Unexpected Complications in Term Newborns measure, PC-06, measures the rate of infants with unexpected newborn complications among full-term newborns with no preexisting conditions per 1000 livebirths. PC-06 assesses health outcomes of term infants, that represent more than 90% of all births, since metrics to assess the health outcomes of this patient population are lacking. This measure addresses this gap and gauges adverse outcomes resulting in severe or moderate morbidity in otherwise healthy term infants without preexisting conditions.

Additionally, this metric also serves as a balancing measure for other maternal measures such as PC-02, Cesarean Birth, and PC-01, Elective Delivery. The purpose of a balancing measure is to guard against any unanticipated or unintended consequences of other performance measures and to identify unforeseen complications that might arise as a result of quality improvement activities and efforts for these measures.

*Data from 2018 and 2019 will be used for the initial release of PC-02. Moving forward, the overall 24-month aggregate rate will be calculated from a rolling eight calendar quarters and refreshed on Quality Check® biannually in July and January. Because of the COVID-19 pandemic, the usability of 2020 data will need to be analyzed and a determination made as to the methodology to address this time period.

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About The Joint Commission
Founded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission accredits and certifies more than 22,000 health care organizations and programs in the United States. An independent, nonprofit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care. Learn more about The Joint Commission at www.jointcommission.org.

Media Contact:
Maureen Lyons
Corporate Communications
(630) 792-5171
mlyons@jointcommission.org

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