T
he Joint Commission announced the hospitals that earned recognition in the Top Performer on Key
Quality Measures® program. These hospitals demonstrated consistently excellent performance on evidence-based process of care measures. This is the fifth consecutive year for the program.
To be named a Top Performer, a hospital must meet three criteria. First, it must achieve at least a 95% composite rate, which is an aggregation of all reported accountability measures, including those with fewer than 30 reported cases. Second, it must achieve at least a 95% rate for each individual accountability measure that has a sample size
of 30 or more cases. Finally, it must have at least one core measure set that has both a composite rate of 95% or above and a performance rate of 95% or above for each applicable accountability measure within that set.
No special applications are required; all hospitals that submit performance data to The Joint Commission through the ORYX® Initiative are automatically eligible for recognition. Measure set data must be reported for a
minimum of 12 months to be included in the calculation. Data used to determine the 2015 Top Performer hospitals were reported from January 2014 through December 2014.
The 2015 Top Performer on Key Quality Measures program included data from 12 core measure sets with a total of 49 accountability measures, up from the previous year’s 10 sets with 44 total measures. New measures were included in the two new measure sets: substance use and tobacco treatment. One measure in the inpatient psychiatric services set, formerly a test measure, was made an accountability measure and therefore included in calculations.
The current list of measure sets (with number of included measures) is as follows:
Heart attack care (7)
Heart failure care (1)
Pneumonia care (3)
Surgical care (7)
Children’s asthma care (3)
Inpatient psychiatric services (6)
Venous thromboembolism (VTE) care (5)
Stroke care (8)
Perinatal care (2)
Immunization (1)
Tobacco treatment (3)
Substance use (3)
In addition, the acute care hospitals must now submit data on 6 selected core measure sets, an increase from the previously required 4 sets.
In 2015, 1,043 hospitals (31.5%) met or surpassed the required thresholds and were recognized as Top Performer hospitals. This is a decrease of about 5.5% from last year’s program. There were 23 hospitals that received recognition for achieving Top Performer–level performance on seven or more core measure sets. This is a significant decrease (about 50%) from 2014. These decreases are due to the higher number
of measures, measure sets, and reporting requirements (see above), which set a higher bar for performance.
Many of this year’s Top Performer hospitals had achieved the distinction before. Of 2015’s Top Performer hospitals, 650 had been recognized for the last two consecutive years; 435 for the past three years; 221 for the past four years; and 117 all five years of the program.
In addition to the Top Performer hospitals, 665 hospitals (20.1%) were identified as being “on track” for recognition. This means the hospital missed qualifying by only one measure. Of last year’s 718 on-track hospitals, 204 (28.4%) achieved Top Performer status this year.
There are 2015 Top Performer hospitals in all 50 states, plus Washington, D.C., Puerto Rico, and Department of Defense international locations in Europe and the Pacific. California and Texas had the most Top Performer hospitals (195), followed by Florida (85) and Pennsylvania (49).
Analysis of Measures
According to the performance data submitted in 2014, some measures were more problematic than others—meaning those measures had the highest number of hospitals failing
to achieve the 95% performance rate threshold for the Top Performer program.
The full list of 10 missed measures can be found in Figure 1, below.
Overall Performance
The Joint Commission compiles composite rates for accountability measures to track performance of all accredited hospitals for all measures. These numbers help The Joint Commission identify widespread weaknesses and prioritize them for focused attention. For example,
if a measure’s composite performance rate decreases significantly, The Joint Commission may choose to study that measure in detail, determine the potential cause for the decline, and create new resources or initiatives to increase performance.
In 2014 the compliance rate for all accountability measures, in all measure sets, for all accredited organizations, was 97.2%. This is slightly lower than 2013’s rate of 97.6%. This is because the two new measure sets, tobacco treatment and substance use, had relatively low rates (75.8% and 58.2%, respectively). This is common
for new measures and sets, and past trends indicate an immediate rise in rates the following year. For example, the first year perinatal measures were required, the
performance rate was 74.1%, but the subsequent year the rate jumped to 96.3%.
Five of the six new measures associated with the two new measure sets were among the most problematic measures for hospitals in 2014. Other frequently problematic measures have historically low numbers, such as the “fibrinolytic therapy within 30 minutes”
measure from the heart attack care measure set, which has consistently hovered just above the 60% performance rate.
The five most problematic measures for hospitals over the last five years (2010–2014) are as follows:
Continuing care plan created, for age 65 and above (inpatient psychiatric services set): –2.5%
Appropriate prophylactic antibiotics, for hip joint replacement surgery (surgical care set): –0.2%
Appropriate prophylactic antibiotics, for cardiac surgery (other than CBAG) (surgical care set):
–0.1%
Continuing care plan transmitted, for age 65 and above (inpatient psychiatric services set): –.01%
Fibrinolytic therapy within 30 minutes (heart attack care set): -0.5%
This list does not include those measures that are not included in calculating the composite scores, nor any test measures.
Performance Measure | Measure Set | Composite Performance Rate |
Tobacco use treatment provided or offered at discharge* | Tobacco treatment* | 36.4% |
Alcohol use brief intervention provided or offered at discharge* | Substance use* | 48.2% |
Exclusive breast milk feeding† | Perinatal care | 49.4% |
Tobacco use treatment provided or offered* | Tobacco treatment* | 51.2% |
Justification for multiple antipsychotic medications (composite for all age groups) | Inpatient psychiatric services | 56.0% |
Alcohol use screening* | Substance use* | 58.2% |
Fibrinolytic therapy within 30 minutes | Heart attack care | 60.0% |
Alcohol and other drug use treatment provided or offered at discharge* | Substance use* | 62.6% |
Thrombolytic therapy | Stroke care | 84.6% |
Continuing care plan transmitted (composite for all age groups) | Inpatient psychiatric services | 86.3% |
*New for 2014. †Retired as an accountability measure effective October 1, 2015, discharges.
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Benchmark
(continued from page 9) Sidebar 1: Core Measure Solution
The Top Performer program has proven valuable for hospitals as a performance improvement tool. Because they eliminate bias by relying solely on objective, quantifiable performance data, the performance rates provide an accurate representation of a hospital’s actual performance excellence. The measures used to determine recognition are commonly accepted, evidence-based processes of care that are common to all hospitals, regardless of their size or
focus. Also, because these measures evaluate a hospital’s use of processes, they are not susceptible to the difficulty in determining cause that can occur when outcomes are used as a basis for evaluation.
Another advantage of the Top Performer program is that it is based on data that organizations collect themselves throughout the year. This means a hospital
can assess its own performance and know ahead of time whether it is meeting the 95%/95% thresholds.
The specificity of the measures is another strength of the program, because it allows hospitals to target areas for improvement, particularly if a hospital has narrowly
missed recognition. And encouraging improvement is, after all, the underlying goal of The Joint Commission and, by extension, the Top Performer program. Hospitals looking
to improve their performance are encouraged to use the Core Measure Solution Exchange®, a free resource available to accredited organizations (see Sidebar 1, right, for more information on the Core Measure Solution Exchange).
Hospitals achieving Top Performer status receive a letter and certificate of recognition, along with a
communications toolkit to help promote the achievement both internally and to the media. Top Performer hospitals are also recognized in the Improving America’s Hospitals annual report, on The Joint Commission’s Quality Check® site, in publications such as Perspectives and The Source, and on The Joint Commission’s website.
The Top Performer program will be on hiatus for 2016. The Joint Commission is reevaluating the program and exploring ways to adapt it to a changing health care environment. The Centers for Medicare & Medicaid Services (CMS) recently retired a number of chart-based measures to allow more
flexible reporting options, including the introduction of electronic clinical quality measures (eCQMs). To maintain its alignment with CMS, The Joint Commission is making these same changes. The Top Performer program must be
Exchange®
The Joint Commission sees performance measurement as a way to encourage hospitals to increase the quality and safety of the care they provide. To this end, The Joint Commission provides a number of tools and resources to its accredited organizations that support their improvement efforts.
Chief among these is the Core Measure Solution Exchange. It is an online database of real-world success stories shared by accredited hospitals that have attained and sustained excellent performance on core measures, including accountability measures.
Joint Commission–accredited and –certified hospitals can access the Exchange through the Joint Commission Connect extranet. Each solution is reviewed and approved by Joint Commission experts, and organized by measure set.
The Exchange allows hospitals to do the following:
Search for solutions related to specific core
measures
Participate in online discussions about the solutions
Rate a solution’s usefulness and adaptability
Post adapted versions of the solutions, based on the hospital’s own experiences
Receive e-mail notifications when new solutions
are posted
For more information on the Core Measure Solution Exchange, visit www.jointcommission.org/core
_measure_solution_exchange/.
reworked to accurately reflect and compare performance using these new systems.
During the hiatus, hospitals will continue to collect and report their ORYX accountability measures data. The Joint Commission will continue to support all its hospitals,
including Top Performer hospitals, with key components such as recognition categories, education opportunities, and an annual report.
Questions about the Top Performer program should be sent via email to topperformersprogram
@jointcommission.org. TS