Hospitals make strides on quality measures, mirror CMS results, Joint Commission report says
Measures are closely aligned to those of the Hospital Inpatient Quality Reporting Program by the Centers for Medicare and Medicaid Services.
A new Joint Commission report has found that hospital performance on accountability measures closely aligned with those of government quality reporting, and continues to improve.
The commission measured specific conditions at about 3,300 hospitals accredited by the commission, including inpatient psychiatric services, venous thromboembolism (VTE), stroke, perinatal care, tobacco use treatment, and substance use.
The measures closely aligned to those of the Hospital Inpatient Quality Reporting Program by the Centers for Medicare and Medicaid Services.
The 2015 VTE care result of 95.2 percent was up from 89.9 percent in 2011, an improvement of 5.3 percentage points. As a result, three of four individual VTE care accountability measures were retired as of December 31, 2015.
The 2015 stroke care result swelled to 97.7 percent from 94.9 percent in 2011, an improvement of 2.8 percentage points. Eight individual stroke care accountability measures were subsequently retired effective December 31, 2015.
The perinatal care result rose significantly to 97.6 percent from 53.2 percent in 2011, an improvement of 44.4 percentage points.
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Tobacco use treatment results were up 8.4 percentage points to 84.2 percent from 75.8 percent in 2014.
The substance use care result of 77.5 percent from 58.2 percent in 2014 constituted an improvement of 19.3 percentage points.
Inpatient psychiatric services results were up 3 percent from 2011, from 87.3 percent to 90.3 percent.
Year to year, between 2014 and 2015, the findings show: Inpatient psychiatric services of 90.3 percent in 2015, compared to 89.9 in 2014; Venous thromboembolism care, 95.2 percent compared to 94.6; Stroke care, 97.7 percent compared to 97.7; Perinatal care, 97.6 compared to 96.3 percent; Tobacco treatment, 84.2 compared to 75.8; and substance use, 77.5 compared to 58.2 percent.
The number of accountability measures decreased to 29 down from 49 in 2014, after the commission retired 20 accountability measures that had excellent quality performance, and also to maintain alignment with CMS's Hospital Inpatient Quality Reporting Program.
In addition, the retirement of the measures was made to reduce the reporting burden and to help hospitals focus on areas where there is opportunity to improve, according to the report.
Because of the retirement of some measures, the 2015 overall composite score on accountability measures is 93.7 percent, down from 97.2 in 2014.
For the same reason, the percentage of hospitals achieving 95 percent declined to 61 percent, down from 80.3 percent in 2014.
In 2015, improvements on individual measures have ranged from small fractions of a percentage point to 24.3 percentage points. Relatively small percentage-point improvements in measures for which performance is already strong can often require as much or even more diligence than large percentage-point improvements where much room for improvement exists, the report said.
Along with retiring 20 measures, in 2015, The Joint Commission introduced flexible reporting options to allow organizations choice in which measures to report, and accepted electronic clinical quality measure (eCQM) data for the first time.
There were 21 available eCQMs from which Joint Commission-accredited hospitals could select and report performance data.
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To support hospitals in making the transition to eCQM reporting, The Joint Commission introduced the Pioneers in Quality program and coordinated it with the Core Measure Solution Exchange.
Going forward, the commission plans to introduce a new recognition program within the coming months with new criteria for highlighting pioneering hospitals that are using eCQMs and are sharing their lessons learned with other hospitals.
While the data show impressive gains in hospital quality performance, improvements can still be made, the report said. Some hospitals perform better than others in treating particular conditions, according to Joint Commission President and CEO Mark R. Chassin, MD, and David W. Baker, MD, executive vice president, Division of Health Care Quality Evaluation.
Accountability measures are evidence-based care processes closely linked to positive patient outcomes. These measures are most suitable for use in programs that hold providers accountable for their performance to external oversight entities and to the public.
The Joint Commission has been involved in performance measurement for 26 years. The commission took a hiatus during 2016 to address new quality improvement challenges.
An independent, not-for-profit organization, the Joint Commission accredits and certifies nearly 21,000 healthcare organizations and programs in the United States.
Twitter: @SusanJMorse
