Evaluating Local Hospital Performance
Health care consumers can assure the best care for themselves and their families by comparing hospital quality and safety, asking doctors questions, considering options, and making informed decisions. The most comprehensive directory of health care facilities available, Quality Check® — www.qualitycheck.org —helps to educate the public about the choices available to them. Individuals may freely view and download hospital-specific performance measurement data from The Joint Commission’s Quality Check website, which now includes organizations that are not accredited by The Joint Commission, as well as Joint Commission-accredited organizations. Joint Commission-accredited organizations are easily identified by The Joint Commission’s Gold Seal of Approval™. The non-accredited organizations added will include several thousand home care, long-term care, and ambulatory care organizations.
The Joint Commission strives to make the information provided on Quality Check as understandable and clear as possible so that people can make more informed decision about their care. Feedback from both health care professionals and consumers was used recently to guide the redesign of the website and to refine and clarify the Quality Reports on each accredited health care organization.
As shown in the following illustration, health care consumers can search by hospital name, zip code or state at www.qualitycheck.org.
Results for a specific hospital can be viewed online, or a Quality Report can be downloaded and printed.
Understanding Quality Check’s Performance Measurement Data
The performance measurement data is organized into hospital performance against National Patient Safety Goals (NPSGs) and National Quality Improvement Goals (NQIGs). Overall performance is signified by either a “
” or "–”. For NPSGs, the “” or “–” signifies whether or not the hospital has implemented the Goal requirement. For NQIGs, a “” means the hospital’s performance is equal to or better than the national average. A “–“ means the hospital’s performance is below average.
Hospital performance against NQIGs is also reported for core measure sets, each of which relates to a condition of care. The core measure sets are heart attack care, heart failure care, pneumonia care, pregnancy care, and surgical care. Hospitals are required to pick a minimum of three measure sets and submit data for all the measures within a measure set. Each measure is either a process measure or an outcome measure. A process measure describes how often a recommended treatment or activity is done (for example, a treatment such as aspirin at arrival) in a patient population over a set time period. A process measure is expressed as a percentage, or rate, of the total number of patients for whom the treatment or activity was recommended. An outcome measure describes the end result of a function or process in a patient population over a set period of time. An outcome measure is expressed as a percentage, or rate, of the total number of patients at risk for the outcome.
The data in each hospital’s report includes:
- Hospital Compliance Result. The percentage of time the hospital performed the measure when it was recommended.
- Total Patients. The total number of patients treated with the measure.
- Nationwide - Average Rate. The average performance rate for all Joint Commission-accredited health care organizations in the nation that provided results for a measure. The average rate is calculated by dividing the total number of patients who received the recommended care provided for a measure by the total number of patients who met the inclusion and exclusion criteria for that measure.
- Nationwide - Top 10%. The percentage of time hospitals with results in the nation’s top 10 percent for that measure provided the recommended treatment.
- Statewide - Average Rate. The average performance rate for all Joint Commission-accredited health care organizations in the state that provided results for a measure. The average rate is calculated by dividing the total number of patients who received the recommended care provided for a measure by the total number of patients who met the inclusion and exclusion criteria for that measure in the state.
- Statewide - Top 10%. The percentage of time hospitals with results in the state’s top 10 percent for that measure provided the recommended treatment.
Hospitals submit data to an intermediary called a performance measurement system, which aggregates a hospital’s data and sends this aggregated data to The Joint Commission quarterly. The Joint Commission then aggregates this quarterly data over the last four reported quarters for reporting on Quality Check.
Uses of Quality Check Data
Quality Check data includes national rates, state rates, and hospital rates at the measure level. Data may be analyzed in many ways. Comparisons may be made from the hospital to national/state level. Comparisons between hospitals may be made. Hospitals with known similar characteristics may have their rates combined and compared to various benchmarks, either provided by The Joint Commission data download or to an outside credible source. To be valid, comparisons must be consistent and use the same measures.
Individuals can download any of the performance measure results available for hospitals on Quality Check by clicking on the Quality Data Download tab. The information—which is provided free of charge to any external third party—can then be saved electronically or printed out. The availability of this data supports the Joint Commission’s commitment to transparency in calculating performance measures and allows for flexibility in customizing performance measure results for use in performance improvement initiatives and quality of care-related reporting.