America s Hospitals: Improving Quality and Safety. Annual Report

Transcription

1 America s Hospitals: Improving Quality and Safety Annual Report 2017

2 TABLE OF CONTENTS Leaders Letter 3 Executive Summary 4 Graph 1: Percent of hospitals with overall accountability composite greater than 95 percent 6 Pioneers in Quality 7 List 1: 2017 Pioneers in Quality Expert and Solution Contributors 8 ecqm Data Summary 9 Table 1: Number of ecqm sets submitted for Graph 2: Most frequently reported ecqms for Table 2: Summary of values for ecqms reported in List 2: 2016 electronic clinical quality measures (ecqms) 12 Accountability Measures Summary 13 Table 3: Measure set composite results for accountability measures 13 Table 4: Percentage of hospitals achieving composite rates greater than 95 percent for accountability measure sets 13 List 3: 2016 accountability measures 14 National Performance Summary 15 Table 5: Inpatient psychiatric services measure results 15 Table 6: Inpatient psychiatric services rate measure results 16 Table 7: Venous thromboembolism (VTE) care measure results 18 Table 8: Stroke care measure results 18 Table 9: Perinatal care measure results 19 Table 10: Immunization measure results 19 Table 11: Tobacco use treatment measure results 19 Table 12: Substance use care measure results 20 Table 13: Percentage of hospitals achieving 95 percent or greater performance 20 State Maps 21 State Maps 1: Inpatient psychiatric services measures 21 State Maps 2: Venous thromboembolism (VTE) care measures 22 State Maps 3: Stroke care measures 22 State Maps 4: Perinatal care measures 23 State Maps 5: Immunization measure 24 State Maps 6: Tobacco use treatment measures 24 State Maps 7: Substance use care measures 26 Understanding the Quality of Care Measures 28 Glossary 32

3 LEADERS LETTER The last year has been a time of tremendous change and many challenges in quality measurement with the expansion of requirements for electronic clinical quality measure (ecqm) reporting. The Joint Commission believes that care processes and patient outcomes can be improved and sustained only through the gathering and analysis of performance data and by an organized and comprehensive approach to performance improvement. In 2016, The Joint Commission created the Pioneers in Quality program to assist hospitals in their adoption of ecqms. This year, we begin our report, America s Hospitals: Improving Quality and Safety The Joint Commission s Annual Report 2017, by recognizing the first hospitals that have successfully leveraged ecqms and health IT to drive quality improvement. Joint Commission-accredited hospitals could select and report performance data on 23 different ecqms in eight measure sets during 2016, and we aligned these requirements as closely as possible to those for the Centers for Medicare & Medicaid Services (CMS) Hospital Inpatient Quality Reporting Program. This year, 470 Pioneers in Quality Data Contributors voluntarily provided 2016 ecqm data to The Joint Commission. Of these hospitals, 11 were named Solution Contributors by submitting a proven practice to The Joint Commission s Proven Practices Collection, and nine achieved the status of Expert Contributors by advancing the evolution and use of ecqms. Meanwhile, Joint Commission-accredited hospitals continue to make strides in performance on our traditional core quality measures. Since 2002, when The Joint Commission began following performance on core quality measures, improvements have been tracked and the bar raised each year. Accountability measures are evidencebased care processes closely associated with positive patient outcomes. A total of 14 core measures were retired by CMS and The Joint Commission at the end of 2015 because performance was consistently very high; this year s report documents 2016 performance on the remaining 15 different chart-abstracted accountability measures in seven measure sets. The data summarized in this report represents 17.3 million opportunities to provide evidence-based patient care, and performance continues to be outstanding. Because of the close link between these measures and patient outcomes, we can be confident that these measures are helping to drive quality improvement and lower patient morbidity and mortality. Sincerely, Mark R. Chassin, MD, FACP, MPP, MPH President and Chief Executive Officer The Joint Commission Mark R. Chassin, MD David W. Baker, MD Hospitals have gained increased confidence in reporting ecqm data, thanks in part to the assistance provided by the Pioneers in Quality program, and most plan to report these data in 2017, according to surveys conducted by The Joint Commission. David W. Baker, MD, MPH, FACP Executive Vice President Division of Health Care Quality Evaluation The Joint Commission 3

4 EXECUTIVE SUMMARY The last year has been a time of tremendous change and many challenges in quality measurement with the expansion of requirements for electronic clinical quality measure (ecqm) reporting. In 2016, The Joint Commission created the Pioneers in Quality program to assist hospitals in their adoption of ecqms. Therefore, we begin our report, America s Hospitals: Improving Quality and Safety The Joint Commission s Annual Report 2017, by discussing ecqm reporting to The Joint Commission and recognizing the first hospitals that have successfully leveraged ecqms and health IT to drive quality improvement. Joint Commission-accredited hospitals could select and report performance data on 23 different ecqms in eight measure sets during 2016, and we aligned these requirements as closely as possible to those for the Centers for Medicare & Medicaid Services (CMS) Hospital Inpatient Quality Reporting Program. The report then discusses performance on our traditional core quality measures. A total of 14 core measures were retired by CMS and The Joint Commission at the end of 2015 because performance was consistently very high; this year s report documents 2016 performance on the remaining 15 different chart-abstracted accountability measures in seven measure sets. This year s report shows hospitals continued strong performance on these measures. While the data show impressive gains in hospital quality, improvements can still be made. Some hospitals perform better than others in treating particular conditions. More than 3,200 Joint Commission-accredited hospitals contributed data. Quality and safety results for specific hospitals can be found at The key findings of the report are: hospitals reported ecqm data in This represents a dramatic increase from the 34 hospitals that voluntarily submitted ecqm data in In 2017, we expect that the number of reporting hospitals will increase to more than 2,000. We recognize: 470 Data Contributors: Hospitals that voluntarily transmitted ecqm data for The Joint Commission s production database. Nine Expert Contributors: Hospitals that advanced the evolution and utilization of ecqms through contributions, by presenting at a Pioneers in Quality webinar or participating in ecqm development. 11 Solution Contributors: Hospitals that submitted a Proven Practice selected for inclusion in The Joint Commission s Proven Practices Collection. Introduced in April, the Proven Practices Collection is a new resource available to Joint Commission-accredited hospitals. This new initiative recognizes hospitals that have successfully leveraged ecqms and health IT to drive quality improvement. The success stories of the Expert and Solution Contributors are shared via the Pioneers in Quality webinars, which assists hospitals on their journey toward ecqm adoption. 4

5 EXECUTIVE SUMMARY (cont.) In 2016, improvements on several individual measures increased as much as 9.8 percentage points. Performance on a few individual measures declined slightly. Relatively small percentage-point improvements on 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. All improvements are important and contribute to better care for patients. The 2016 inpatient psychiatric services result is 92.1 percent, up from 89.7 percent in 2012 an improvement of 2.4 percentage points. 2. Two voice of the customer surveys on ecqms conducted by The Joint Commission found that awareness of ecqm reporting requirements is very high and most hospitals plan to report 2017 ecqm data to CMS. Compared to hospitals responding to the first survey conducted in spring 2016, hospitals participating in the second survey in fall 2016 revealed: More willingness to report voluntarily More confidence about the accuracy of their ecqm data Increased perceived readiness to successfully submit ecqm data Increased confidence in generating quality reporting document architecture (QRDA) Category 1 documents The ability to submit using their own electronic health records (EHR) data 3. Hospital performance on accountability measures continued to be strong, greatly enhancing the quality of care provided in Joint Commission-accredited hospitals. Accountability measures are evidence-based care processes closely associated with positive patient outcomes. The 2016 overall accountability composite calculation is derived from a total of 15 accountability measures from seven sets (inpatient psychiatric services, venous thromboembolism (VTE) care, stroke care, perinatal care, immunization, tobacco use treatment, and substance use care). The 2016 perinatal care result is 98.1 percent, up from 57.6 percent in 2012 an improvement of 40.5 percentage points. The 2016 tobacco use treatment result is 87.7 percent, up from 75.8 percent in 2014 an improvement of 11.9 percentage points. The 2016 substance use care result is 82.2 percent, up from 58.2 percent in 2014 an improvement of 24.0 percentage points. The heart attack and children s asthma care accountability measures included in last year s report have been retired. There are no VTE, stroke or immunization measure set composites this year because a measure set composite must have at least two measures and these measure sets are comprised of only one accountability measure. Performance on the individual measures on these clinical topics showed good improvement. The VTE warfarin discharge instructions measure result is 92.9 percent, up from 82.2 percent in 2012 an improvement of 10.7 percentage points. The stroke care thrombolytic therapy result is 89.6 percent, up from 77.3 percent in 2012 an improvement of 12.3 percentage points. The influenza immunization measure result is 94.3 percent, up from 86.2 percent in 2012 an improvement of 8.2 percentage points. 5

6 EXECUTIVE SUMMARY (cont.) Performance on the above three measures was included in the overall accountability composite results. Composite accountability measures have been compiled for inpatient psychiatric services, VTE and stroke care since 2011, for perinatal care and immunization since 2012, and for tobacco use treatment and substance use care since The composites for each year are calculated on measures active for the entire year; active measures can change from year to year. For more information about accountability composite results versus composite results, see Note on Calculations and Methodology. 4. The 2016 composite accountability score declined slightly, which we believe is due to the retiring of measures that had a very high performance in the past. The Joint Commission analyzes improvement with a composite result, which sums up the results of individual accountability process measures into a single summary score. While the composite performance increased for all the measure sets, the overall composite decreased slightly from 93.7 percent in 2015 to 92.4 percent in This is due to the fact that 14 measures that had been used for many years were retired. These retired measures contributed roughly half of all cases to the 2015 accountability composite rate. Thus, the apparent decrease in the composite score from 2015 to 2016 is a result of removing these measures. Since implementation in 2002, the average number of hospitals reporting data was 3,262 and ranged from 3,073 to 3,419. The retirement of the measures was made to reduce the burden of reporting on organizations and to allow them to focus on areas where there are still significant opportunities to improve. The report also includes performance data on two non-accountability process measures noted within the measure sets (VTE-6: Incidence of potentially preventable VTE, and PC-05: Exclusive breast milk feeding), and two outcome measures (PC-02: Cesarean section, and PC-04: Newborn bloodstream infections). The overall composite accountability score reflects 17.3 million opportunities to perform care processes closely linked to positive patient outcomes. Since the baseline has been significantly altered by the retirement of the measures, caution should be taken when comparing the 2015 and 2016 composite scores. Measure sets with composite performance below the overall composite rate of 92.4 percent are inpatient psychiatric services (92.1 percent), tobacco use treatment (87.7 percent), and substance use care (82.2 percent). The 92.4 percent result identifies the rate at which evidencebased core measure practice is provided combined over all hospitals for every 100 opportunities to do so. The 59.6 percent result measures the percentage of hospitals achieving overall composite performance greater than 95 percent. Graph 1: Percent of hospitals with overall accountability composite greater than 95 percent 6

7 PIONEERS IN QUALITY Pioneers in Quality is a Joint Commission program started in 2016 to assist hospitals on their journey toward electronic clinical quality measure (ecqm) adoption and reporting. Hospitals collect ecqm information through electronic health records (EHRs) and transmit the data to The Joint Commission (as part of its ORYX performance measurement requirements) and to the Centers for Medicare & Medicaid Services (CMS). The Pioneers in Quality program provided resources to aid hospitals in the transition from chart-abstracted measures to ecqms. Key components of the Pioneers in Quality program include: Regular educational webinars focused on ecqm adoption, including continuing education units (CEUs) for live webinar participation Expert-to-Expert series webinars A comprehensive ecqm resource portal The Joint Commission s annual report, focusing on components of the program and the evolution of ecqm measurement Recognition for ecqm pioneers, including in the annual report A Pioneers in Quality Technical Advisory Panel Outreach through The Joint Commission s Speaker s Bureau In 2016, 470 hospitals chose to submit ecqm data; those hospitals were asked to submit a minimum of one quarter of data. The 470 hospitals are an increase from the 34 hospitals that voluntarily submitted ecqm data in In 2017, the number of reporting hospitals is expected to increase to more than 2,000. Pioneers in Quality recognizes hospitals in three categories: 470 Data Contributors: Hospitals that voluntarily transmitted ecqm data for The Joint Commission s production database. Nine Expert Contributors: Hospitals that advanced the evolution and utilization of ecqms through contributions, by presenting at a Pioneers in Quality webinar or participating in ecqm development. 11 Solution Contributors: Hospitals that submitted a Proven Practice selected for inclusion in The Joint Commission s Proven Practices Collection. See the 2017 Pioneers in Quality Expert and Solution Contributors. The Pioneers in Quality : Proven Practices Collection is a new resource that will be available to Joint Commissionaccredited hospitals. In spring 2017, hospitals submitted their success stories via an online application form that asked applicants to clearly link their accomplishments to the use of ecqms and health IT for quality improvement. While this annual report shares high-level ecqm data, The Joint Commission is not publicly reporting 2016 and 2017 ecqm data on Quality Check because the accuracy of ecqms continues to be a concern. Hospitals reporting on chart-abstracted measures will continue to have their data and performance on the chart-abstracted measures reported on Quality Check. The Joint Commission aligned our ecqm reporting requirements as closely as possible to the CMS Hospital Inpatient Quality Reporting Program. During 2016, there were 23 ecqms from which Joint Commission-accredited hospitals could select and report performance data. For more information on Pioneers in Quality or the Proven Practices Collection, visit the Pioneers in Quality web portal, which includes the 2017 ecqm Data Contributors being recognized by The Joint Commission. 7

8 PIONEERS IN QUALITY (cont.) Pioneers in Quality is a Joint Commission program started in 2016 to assist hospitals on their journey toward electronic clinical quality measure (ecqm) adoption and reporting. List 1: 2017 Pioneers in Quality Expert and Solution Contributors Hospital Expert Contributor Solution Contributor BayCare Health System, Inc., Clearwater, Florida Centura Health-Penrose St. Francis Health Services, Colorado Springs, CO Hospital Corporation of America (HCA), Nashville, Tennessee MedStar St. Mary s Hospital, Leonardtown, Maryland Memorial Hermann Healthcare System, Houston, Texas OSF Saint Elizabeth Medical Center, Ottawa, Illinois Providence Sacred Heart Medical Center, Spokane, Washington Rush University Medical Center, Chicago, Illinois St. Luke s Cornwall Hospital, Newburgh, New York St. Mary Medical Center, Langhorne, Pennsylvania Trinity Health, Livonia, Michigan TriStar Centennial Medical Center, Nashville, Tennessee University Medical Center New Orleans, New Orleans, Louisiana UPMC, Pittsburgh, Pennsylvania Virginia Commonwealth University Health System, Richmond, Virginia 8

9 ecqm DATA SUMMARY Since 2002, hospitals have been reporting data to The Joint Commission as a requirement of accreditation. Through electronic clinical quality measures (ecqms), hospitals can electronically collect and transmit data on the quality of care that patients receive data that can be analyzed to measure and improve care processes, performances and outcomes. by the information that is captured in a structured and encoded fashion in an EHR system. For example, a chart-abstracted data element may be represented by multiple data elements in the ecqm. Data sources for ecqms are more limited than data sources used for chart-abstracted measures: ecqms rely solely on data that is captured in a structured and encoded fashion in the EHR. In addition, ecqms typically rely on a single structured data field in the EHR for a given data element. Discrepancies in rates often happen when data is not consistently captured in the field selected for data extraction. Recent changes to The Joint Commission s ORYX performance measurement requirements are the result of the transition to ecqms, as well as efforts to maintain close alignment with the Centers for Medicare & Medicaid Services (CMS) Hospital Inpatient Quality Reporting Program. Why are ecqm rates different from chartabstracted measure rates? Due to the differences in how ecqms and chartabstracted measures are calculated, it is not surprising that we see apparent differences in performance rates. Performance rates on ecqm measures appear to be lower than expected when compared to the rates of chart review measures. There are several reasons why ecqm rates are different from chart-abstracted measure rates: Specifications for ecqms and chart-abstracted specifications are different: The representation of data elements and inclusions and exclusions are constrained by the standards used to represent ecqms, as well as Release schedules and updates for ecqm specifications and chart-abstracted specifications are not always aligned: While there are continued efforts to keep ecqms and chart-abstracted measure specifications as closely aligned as possible, ecqm specifications updates are released on a different schedule than the chartabstracted measures manual. Updates for ecqms are published once a year in early spring, whereas the chart-abstracted measures manual is released twice a year, in January and July. Voice of the customer survey on ecqms During 2016, The Joint Commission conducted two voice of the customer surveys on ecqms one in the spring and another in the fall. The surveys found that awareness of reporting requirements is very high and for 2017 most hospitals plan to report ecqms to CMS, as required. Compared to responses to the first survey, hospitals participating in the second survey showed more willingness to report voluntarily, more confidence about the accuracy of their ecqm data, increased perceived readiness to successfully submit ecqm data, Align with CMS so we are doing the same thing for both. increased confidence in generating quality reporting document architecture (QRDA) Category 1 documents, and greater ability to submit EHR data. 9

10 ecqm DATA SUMMARY (cont.) Comments from accredited hospitals included requests for more alignment with CMS to make data submission more efficient, and that changes to workflow and processes were necessary for ecqm reporting. Specific comments included: Graph 2: Most frequently reported ecqms for 2016 Align with CMS so we are doing the same thing for both. There is a ton of work to be done to prepare for ecqms that include workflow changes, documentation changes, education, and follow up on measures. Measure Sets Another customer pointed out the advantage of using electronic methods to measure quality, so that efforts can be focused on improvement rather than obtaining data. Other customers requested support from The Joint Commission via best practices, webinars, and other educational offerings and resources. The Pioneers in Quality program has provided this needed education. We have appreciated the forum to ask questions and discuss concerns, one commented. No. of Hospitals Reporting Measure Sets These topic areas are in alignment with CMS ecqms. The top three areas (eed, evte and estk) are ecqms that hospitals have been reporting for the longest time. See the 2016 ecqms. Table 1: Number of ecqm sets submitted for 2016 Number of ecqm sets submitted Number of hospitals Percent % % % % % % There is a ton of work to be done to prepare for ecqms that include workflow changes, documentation changes, education, and follow up on measures. 10

11 ecqm DATA SUMMARY (cont.) Table 2: Summary of values for ecqms reported in 2016 The rate (%) for the proportion measures listed reflects the percentage of time that recommended care was provided. The value (minutes) for the two eed measures reflects the time patients spend in the emergency department from their arrival until admitted to the hospital, and the time it takes for a patient to be admitted to the hospital after being seen in the emergency department. No hospitals had cases to report for eami-7a: Fibrinolytic therapy within 30 minutes. Also, PC-05: Exclusive breast milk feeding, and PC-05a: Exclusive breast milk feeding considering mother s choice, are counted as one measure. ecqm measure No. of hospitals No. of records Average time Rate (%) eami-8a: Primary PCI received within 90 minutes % ecac-3: Home management plan of care % eed-1a: Median time (minutes) from ED arrival to ED departure for admitted ED patients , eed-2a: Admit decision time (minutes) to ED departure time for admitted patients , eehdi-1a: Hearing screening prior to discharge 12 5, % epc-01: Elective delivery* % epc-05: Exclusive breast milk feeding 16 4, % epc-05a: Exclusive breast milk feeding considering mother s choice % escip-inf-1: Antibiotics within one hour before the first surgical cut % escip-inf-9: Urinary catheter removed % estk-02: Discharged on antithrombotic therapy 52 2, % estk-03: Anticoagulation therapy for atrial fibrillation/flutter % estk-04: Thrombolytic therapy % estk-05: Antithrombolytic therapy by end of hospital day two 54 1, % estk-06: Discharged on statin medication 74 2, % estk-08: Stroke education 36 1, % estk-10: Assessed for rehabilitation 50 2, % evte-1: VTE medicine/treatment , % evte-2: VTE medicine/treatment in ICU , % evte-3: VTE patients with overlap therapy % evte-4: VTE patients with UFH monitoring % evte-5: VTE discharge instructions % evte-6: Incidence of potentially-preventable VTE* % *A lower score reflects better performance for this measure. 11

12 ecqm DATA SUMMARY (cont.) List 2: 2016 electronic clinical quality measures (ecqms) Heart attack care eami-7a: Fibrinolytic therapy within 30 minutes eami-8a: Primary PCI received within 90 minutes Children s asthma care ecac-3: Home management plan of care Emergency department eed-1a: Median time from ED arrival to ED departure for admitted ED patients eed-2a: Admit decision time to ED departure time for admitted patients Hearing screening eehdi-1a: Hearing screening prior to discharge Perinatal care epc-01: Elective delivery epc-05/05a: Exclusive breast milk feeding Surgical care escip-inf-1: Antibiotics within one hour before the first surgical cut escip-inf-9: Urinary catheter removed These topic areas are in alignment with Centers for Medicare & Medicaid Services (CMS) ecqms. The top three areas (eed, evte and estk) are ecqms that hospitals have been reporting for the longest time. Stroke care estk-2: Discharged on antithrombotic therapy estk-3: Anticoagulation therapy for atrial fibrillation/flutter estk-4: Thrombolytic therapy estk-5: Antithrombotic therapy by end of hospital day two estk-6: Discharged on statin medication estk-8: Stroke education estk-10: Assessed for rehabilitation Venous thromboembolism (VTE) care evte-1: VTE medicine/treatment evte-2: VTE medicine/treatment in ICU evte-3: VTE patients with overlap therapy evte-4: VTE patients with UFH monitoring evte-5: VTE discharge instructions evte-6: Incidence of potentially-preventable VTE 12

13 ACCOUNTABILITY MEASURES SUMMARY Composite measures combine the results of related measures into a single percentage rating calculated by adding up the number of times recommended evidencebased care was provided to patients (measure numerator) and dividing this sum by the total number of opportunities to provide this care (measure denominator). a measure set composite must have at least two measures and these measure sets are comprised of only one accountability measure. The heart attack and children s asthma care accountability measure sets included in last year s report have been retired. For more information, see Note on Calculations and Methodology. Composite for accountability measures: The number of accountability measures used in the overall composite rates varies each year. The 2016 overall accountability composite calculation is derived from a total of 15 accountability measures from seven sets (inpatient psychiatric services, venous thromboembolism (VTE) care, stroke care, perinatal care, immunization, tobacco use treatment, and substance use care). Two rate measures from the inpatient psychiatric services set are not included in the overall accountability composite. There are no VTE, stroke or immunization measure set composites because While the composite performance increased for all the measure sets, the overall 2016 composite decreased due to the retirement of 14 accountability measures. Accountability composites for chart-based measures will no longer be calculated after this year s annual report due to the retirement of a significant number of these measures. An accountability composite rate based on so few measures is not meaningful. See Glossary for definitions. Table 3: Measure set composite results for accountability measures Accountability composite measure sets Inpatient psychiatric services composite 89.7% 90.3% 89.9% 90.3% 92.1% Perinatal care composite 57.6% 74.1% 96.3% 97.6% 98.1% Tobacco treatment composite N/A N/A 75.8% 84.2% 87.7% Substance use composite N/A N/A 58.2% 77.5% 82.2% Overall 97.6% 97.6% 97.2% 93.7%* 92.4%* * The overall composite decreased starting in 2015 due to the retirement of high-performing measures. Table 4: Percentage of hospitals achieving composite rates greater than 95 percent for accountability measure sets Accountability composite measure sets Inpatient psychiatric services composite 51.4% 41.9% 43.7% 43.8% 54.9% Perinatal care composite 1.3% 5.6% 73.4% 84.0% 88.1% Tobacco treatment composite N/A N/A 9.7% 21.6% 28.8% Substance use composite N/A N/A 3.2% 10.8% 15.9% Overall 83.0% 81.1% 80.3% 61.0%* 59.6%* Since implementation in 2002, the average number of hospitals reporting data was 3,262 and ranged from 3,073 to 3,419. * The overall composite decreased starting in 2015 due to the retirement of high-performing measures. 13

14 ecqm DATA SUMMARY (cont.) List 3: 2016 accountability measures Inpatient psychiatric services HBIPS-1: Admission screening HBIPS-2: Physical restraint* HBIPS-3: Seclusion* HBIPS-5: Justification for multiple antipsychotic medications Venous thromboembolism (VTE) care VTE-5: VTE warfarin discharge instructions Stroke care STK-4: Thrombolytic therapy Perinatal care PC-01: Elective delivery PC-03: Antenatal steroids Immunization IMM-2: Influenza immunization Tobacco use treatment TOB-1: Tobacco use screening TOB-2: Tobacco use treatment provided or offered TOB-3: Tobacco use treatment provided or offered at discharge Substance use care SUB-1: Alcohol use screening SUB-2: Alcohol use brief intervention provided or offered SUB-3: Alcohol and other drug use treatment provided or offered at discharge * Rate measures not included in composite results The 2016 overall accountability composite calculation is derived from a total of 15 accountability measures from seven sets (inpatient psychiatric services, venous thromboembolism (VTE) care, stroke care, perinatal care, immunization, tobacco use treatment, and substance use care). 14

15 NATIONAL PERFORMANCE SUMMARY Results are determined by the number of times the hospital met the measure divided by the number of opportunities (eligible patients for the measure) the hospital had during the year. Results are expressed as a percentage. All improvements or decreases in performance are statistically significant. Many of the smaller percentage improvements occurred within large patient populations, meaning that significantly more patients received a treatment. In some cases, performance was already quite high and there was less room for improvement. Composite measures combine the results of all individual process measures on a similar medical condition into a single percentage rating calculated by adding up the number of times recommended evidence-based care was provided to patients and dividing this sum by the total number of opportunities to provide this care. Composite for all measures: The composite for all measures calculation is derived from the accountability measures for each measure set. These composite results have historically been provided in previous annual reports, allowing them to be tracked from year to year. Any exclusions to the composite are noted with the tables. See Glossary for definitions. Table 5: Inpatient psychiatric services measure results As in the other measure sets, high rates are preferred in this measure set for two of the measures. The overall measure and rates are indicated in bold; the stratified measures (by specific age ranges of patients) are indicated in regular type. Note: Admission screening became an accountability measure in 2014; it was a test measure in previous reports. Performance measure difference (% points) Inpatient psychiatric services composite 89.7% 90.3% 89.9% 90.3% 92.1% 2.4% Admission screening 96.4% 96.7% 93.8% 93.3% 94.0% -2.4% For age 1-12 years 98.1% 98.1% 98.1% 96.1% 95.4% -2.7% For age years 98.2% 98.4% 98.0% 96.3% 96.2% -2.0% For age years 95.6% 96.1% 93.2% 93.0% 93.7% -1.9% For age 65 and above 95.9% 95.3% 87.6% 91.0% 92.4% -3.5% Justification for multiple antipsychotic medications* 46.7% 52.7% 56.0% 62.1% 61.2% 14.5% For age 1-12 years 51.5% 57.5% 56.2% 58.4% 62.8% 11.4% For age years 46.5% 50.5% 52.2% 59.0% 58.8% 12.3% For age years 46.7% 53.7% 56.9% 63.1% 62.0% 15.3% For age 65 and above 47.0% 46.3% 51.2% 56.3% 56.1% 9.1% Since implementation in 2009, the average number of hospitals reporting data was 718 and ranged from 244 to 2,076. * The full name of the measure is Multiple antipsychotic medications at discharge with appropriate justification overall rate. Test measure; not included in the composite. 15

16 NATIONAL PERFORMANCE SUMMARY (cont.) Table 6: Inpatient psychiatric services rate measure results The following table includes two rate measures: physical restraint hours per 1,000 patient hours and seclusion hours per 1,000 patient hours. In addition, these two measures are stratified by age groups 1-12 years, years, years, and age 65 and above. Lower rates reflect better performance. The overall measure and rates are indicated in bold; the stratified measures (by specific age ranges of patients) are indicated in regular type. Performance measure 2012 Inpatient psychiatric services ratio measures Median Maximum Percent of hospitals with 0 hours Physical restraint (minutes per 1,000 patient hours)* % For age 1-12 years % For age years % For age years % For age 65 and above % Seclusion (minutes per 1,000 patient hours)* % For age 1-12 years % For age years % For age years % For age 65 and above % Performance measure 2013 Inpatient psychiatric services ratio measures Median Maximum Percent of hospitals with 0 hours Physical restraint (minutes per 1,000 patient hours)* % For age 1-12 years % For age years % For age years % For age 65 and above % Seclusion (minutes per 1,000 patient hours)* % For age 1-12 years % For age years % For age years % For age 65 and above % 16

17 NATIONAL PERFORMANCE SUMMARY (cont.) Performance measure 2014 Inpatient psychiatric services ratio measures Median Maximum Percent of hospitals with 0 hours Physical restraint (minutes per 1,000 patient hours)* % For age 1-12 years % For age years % For age years % For age 65 and above % Seclusion (minutes per 1,000 patient hours)* % For age 1-12 years % For age years % For age years % For age 65 and above % Performance measure 2015 Inpatient psychiatric services ratio measures Median Maximum Percent of hospitals with 0 hours Physical restraint (minutes per 1,000 patient hours)* % For age 1-12 years % For age years % For age years % For age 65 and above % Seclusion (minutes per 1,000 patient hours)* % For age 1-12 years % For age years % For age years % For age 65 and above % 17

18 NATIONAL PERFORMANCE SUMMARY (cont.) Performance measure 2016 Inpatient psychiatric services ratio measures Median Maximum Percent of hospitals with 0 hours Physical restraint (minutes per 1,000 patient hours)* % For age 1-12 years % For age years % For age years % For age 65 and above % Seclusion (minutes per 1,000 patient hours)* % For age 1-12 years % For age years % For age years % For age 65 and above % Since implementation in 2009, the average number of hospitals reporting data was 718 and ranged from 244 to 2,076. * A lower ratio is preferred for this measure. Also, it is not included in the composite results because the denominator represents patient days rather than patients, and therefore cannot be combined with the other measures. Table 7: Venous thromboembolism (VTE) care measure results Performance measure difference (% points) Venous thromboembolism (VTE) VTE warfarin discharge instructions 82.2% 85.9% 92.3% 92.6% 92.9% 10.7% Incidence of potentially-preventable VTE 4.2% 6.2% 4.6% 1.8% 1.8% -2.4% Since implementation in 2010, the average number of hospitals reporting data was 913 and ranged from 59 to 2,639. Test measure; not included in the composite. Also, a lower score reflects better performance for this measure, so the negative performance point difference is favorable. Table 8: Stroke care measure results Performance measure difference (% points) Stroke care Thrombolytic therapy 77.3% 79.1% 84.6% 87.1% 89.6% 12.3% Since implementation in 2010, the average number of hospitals reporting data was 972 and ranged from 105 to 2,

19 NATIONAL PERFORMANCE SUMMARY (cont.) Table 9: Perinatal care measure results As in the other measure sets, high rates are preferred in this measure set for two of the measures. However, a lower score reflects better performance on the Cesarean section, elective delivery, and newborn bloodstream infections measures. Performance measure difference (% points) Perinatal care composite 57.6% 74.1% 96.3% 97.6% 98.1% 40.5% Antenatal steroids 81.8% 89.7% 91.8% 97.2% 97.8% 16.1% Cesarean section* 26.3% 25.9% 26.8% 26.2% 26.1% -0.1% Elective delivery* 8.2% 4.3% 3.3% 2.3% 1.9% -6.3% Exclusive breast milk feeding** 50.8% 53.6% 49.4% 51.8% 52.9% 2.2% Newborn bloodstream infections* N/A 2.5% 3.2% 2.4% 1.1% -1.4% Since implementation in 2011, the average number of hospitals reporting data was 1,268 and ranged from 151 to 2,985. * For this measure, a decrease in the rate is desired, so a negative percentage point difference is favorable. ** This measure was included in the composite for 2012, but not subsequently. This measure is an outcome measure and is not included in the composite. Only proportion process measures are included in the composite. Table 10: Immunization measure results Performance measure difference (% points) Immunization Influenza immunization 86.2% 89.9% 95.2% 94.1% 94.3% 8.2% Since implementation in 2012, the average number of hospitals reporting data was 1,313 and ranged from 78 to 2,741. Table 11: Tobacco use treatment measure results Performance measure difference (% points) Tobacco use treatment composite 75.8% 84.2% 87.7% 11.9% Tobacco use screening 94.1% 97.8% 98.6% 4.5% Tobacco use treatment provided or offered 51.2% 60.5% 70.3% 19.1% Tobacco use treatment provided or offered at discharge 36.4% 40.6% 48.9% 12.5% Since implementation in 2014, the average number of hospitals reporting data was 914 and ranged from 68 to 2,

20 NATIONAL PERFORMANCE SUMMARY (cont.) Table 12: Substance use care measure results Performance measure difference (% points) Substance use care composite 58.2% 77.5% 82.2% 24.0% Alcohol use screening 58.2% 82.5% 86.7% 28.4% Alcohol use brief intervention provided or offered 48.2% 58.3% 69.8% 21.6% Alcohol and other drug use treatment provided or offered at discharge 62.6% 66.9% 69.0% 6.5% Since implementation in 2014, the average number of hospitals reporting data was 271 and ranged from 130 to 513. Table 13: Percentage of hospitals achieving 95 percent or greater performance The following table shows percentage of hospitals achieving the annual targeted performance of 95 percent or more compliance on a measure. The last column is reported as percentage points the difference on a percentage scale between two rates, in this case 2015 performance versus 2016 performance. Performance measure 2014 High 2015 High 2016 High (% >95) (% >95) (% >95) difference (% points) Alcohol use screening (Substance use care) 16.8% 33.7% 51.8% 18.0% Tobacco use screening (Tobacco use treatment) 59.0% 84.8% 92.1% 7.3% Tobacco use treatment provided or offered (Tobacco use treatment) 2.6% 15.4% 20.9% 5.5% Thrombolytic therapy (Stroke) 47.1% 57.5% 62.1% 4.6% Alcohol use brief intervention provided or offered (Substance use care) 12.1% 18.5% 22.0% 3.4% Elective delivery (Perinatal)* 77.1% 85.4% 88.7% 3.4% Admission screening (Inpatient psychiatric) 65.4% 65.2% 67.3% 2.1% Tobacco use treatment provided or offered at discharge (Tobacco use treatment) 0.0% 6.4% 8.5% 2.1% Antenatal steroids (Perinatal) 72.5% 92.2% 94.2% 2.0% Alcohol and other drug use treatment provided or offered at discharge (Substance use care) 1.9% 3.1% 3.7% 0.6% Influenza immunization (Immunization) 70.3% 66.4% 66.4% 0.0% Exclusive breast milk feeding (Perinatal) 0.4% 0.5% 0.2% -0.3% Incidence of potentially-preventable VTE (VTE)* 66.3% 90.7% 89.4% -1.3% VTE warfarin discharge instructions (VTE) 59.5% 63.0% 61.4% -1.6% Justification for multiple antipsychotic medications (Inpatient psychiatric) 11.5% 17.3% 12.6% -4.7% * For this measure, a decrease in the rate is desired, so the percentage represented is the percent of hospitals with percentage of 5 percent or less. Test measure; not included in the composite. 20

21 STATE MAPS The following maps show measure performance from the first full year that data was reported compared to 2016 performance. State maps 1: Inpatient psychiatric services measures Admission Screening Justification for Multiple Antipsychotic Medications 21

22 STATE MAPS (cont.) State maps 2: Venous thromboembolism (VTE) care measure VTE Warfarin Discharge Instructions State maps 3: Stroke care measures Thrombolytic Therapy 22

23 STATE MAPS (cont.) State maps 4: Perinatal care measures Antenatal Steroids Elective Delivery 23

24 STATE MAPS (cont.) State maps 5: Immunization measure Influenza Immunization State maps 6: Tobacco use treatment measures Tobacco Use Screening 24

25 STATE MAPS (cont.) State maps 6: Tobacco use treatment measures (cont.) Tobacco Use Treatment Provided or Offered Tobacco Use Treatment Provided or Offered at Discharge 25

26 STATE MAPS (cont.) State maps 7: Substance use care measures Alcohol Use Screening Alcohol Use Brief Intervention Provided or Offered 26

27 STATE MAPS (cont.) State maps 7: Substance use care measures (cont.) Alcohol and Other Drug Use Treatment Provided or Offered at Discharge 27

28 UNDERSTANDING THE QUALITY OF CARE MEASURES This annual report includes results on ORYX quality of care measures reported upon by Joint Commissionaccredited hospitals and critical care hospitals during Reporting on these measures aligns The Joint Commission as closely as possible to the Centers for Medicare & Medicaid Services (CMS) Hospital Inpatient Quality Reporting Program. Why quality of care measures were created, what they report and why the results are important The Joint Commission has been involved in performance measurement for 27 years, viewing it as a critical way to extend the reach and sophistication of the accreditation process. The Joint Commission s 1990 publication, The Primer on Clinical Indicator Development and Application, created a readily adaptable template for performance measure development that is still in use today and established The Joint Commission as a leader in this arena. The Joint Commission continues to be a leader in performance measurement. The data displayed on the CMS Hospital Compare website reflects many measures that The Joint Commission and CMS have in common. A large percentage of that data comes from The Joint Commission via its well-established performance measure data network. Today, this network comprises approximately 31 measurement systems, all under contract to The Joint Commission, and is the source of quality-related data on The Joint Commission s Quality Check website ( America s Hospitals: Improving Quality and Safety The Joint Commission s Annual Report 2017 presents the overall performance of Joint Commission-accredited hospitals on quality of care for chart-based measures relating to inpatient psychiatric services, venous thromboembolism (VTE) care, stroke care, perinatal care, immunization, tobacco use treatment, and substance use care. These measures were chosen because they provide concrete data about the best kinds of treatments or practices for common conditions for which Americans enter the hospital and seek care. The results are important, because they show that hospitals have improved their care quality. The results identify opportunities for further improvement, and support continual measurement and reporting. Quality improvement in hospitals contributes to saved lives, better health, and quality of life for many patients, as well as lower health care costs ORYX performance measure reporting requirements During 2016, Joint Commission-accredited hospitals had continued flexibility in meeting the ORYX performance measure requirements for reporting on a minimum of six measure sets. Only one measure set perinatal care was mandatory as one of the six measure sets for hospitals. The threshold for mandatory reporting on the perinatal care measure set was reduced to 300 or more live births per year (previously, it was 1,100 live births per year). Accredited hospitals had the flexibility of meeting ORYX reporting requirements through one of three options: Option 1: Vendor submission of quarterly data on six of nine sets of chart-abstracted measures. Option 2: Vendor submission of data on six of eight sets of ecqms.* Option 3: Vendor submission of data on six measure sets using a combination of chart-abstracted measures and ecqms.* *For 2016, hospitals could report on as few as one ecqm in an ecqm set and it was counted as an ecqm set. 28

29 UNDERSTANDING THE QUALITY OF CARE MEASURES (cont.) A special focus on accountability measures 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. There has been an evolution of such oversight programs including those for value-based purchasing, accreditation, certification, and public reporting and they are often used to demonstrate quality and cost-efficient performance, to drive market share, and to determine appropriate reimbursements. Each accountability measure meets four criteria that evaluate whether or not evidence-based care processes associated with the measures lead to positive patient outcomes. As new measures are introduced, they are evaluated against the criteria. article suggests a national critical look is needed on how to assess the validity of outcome measures used by public accountability programs. Outcome measures are intended to quantify the end results of a health care service or intervention. Yet, criteria for assessing whether they are accurate and valid enough to use for public reporting, payment and other accountability programs are not well defined. It s important to note that where a patient receives care makes a difference. Not all hospitals deliver the same level of quality; some hospitals perform better than others in treating particular conditions and in achieving patient satisfaction. This variability has been known within the hospital industry for a long time. Designation as an accountability measure is included in the information on Quality Check ( How quality measures are determined For more information about accountability measures, see the New England Journal of Medicine article Accountability Measures Using Measurement to Promote Quality Improvement, for which Mark R. Chassin, MD, FACP, MPP, MPH, president and chief executive officer of The Joint Commission, was the lead author. Also see the Annals of Internal Medicine article, Holding Providers Accountable for Health Care Outcomes, by Dr. Chassin and lead author David W. Baker, MD, MPH, FACP, executive vice president in the Division of Health Care Quality Evaluation at The Joint Commission. This latter The Joint Commission worked closely with clinicians, health care providers, hospital associations, performance measurement experts, and health care consumers across the nation to identify the quality measures. This collaborative process identified measures that reflect the best evidence-based treatments relating to inpatient psychiatric services, VTE care, stroke care, perinatal care, immunization, tobacco use treatment, and substance use care. Current measures are the product of The Joint Commission s Hospital Core Measure Initiative that sought to create sets of standardized national measures that would permit comparisons across organizations. Subsequently, The Joint Commission collaborated with CMS to align common measures to ease data collection efforts by hospitals and to allow the same data sets to be used to satisfy multiple data requirements. Related quality reporting efforts of other organizations The CMS Hospital Compare website (www. hospitalcompare.hhs.gov) reports quality information from over 4,000 Medicare-certified U.S. hospitals, including treatments relating to cataracts, colonoscopy, 29

30 UNDERSTANDING THE QUALITY OF CARE MEASURES (cont.) heart attack, emergency department care, preventative care (immunization), stroke care, blood clot prevention, perinatal care, and medical imaging. Hospital Compare also includes information on patient experiences, readmissions, complications, deaths, and payment and value of care. organizations accredited by CMS-recognized accrediting organizations other than The Joint Commission and some unaccredited organizations. Hospital Compare does not currently include Department of Defense and Indian Health Service hospitals. The National Quality Forum s National Quality Partners (NQP) engages its members including The Joint Commission in health care quality issues of national importance. Data collection and reporting requirements For 2016, The Joint Commission required most hospitals to select six measure sets. Hospitals chose sets best reflecting their patient population and reported on all the applicable measures in each of the sets they choose. Hospitals submitted monthly data on a quarterly basis In addition, CMS in 2013 began receiving data on The Joint Commission s perinatal care elective delivery measure, which was adopted for use in the CMS Hospital Inpatient Quality Reporting Program, and now around 3,300 hospitals are submitting data to CMS on this measure. Joint Commission-developed measures also have been adopted into a number of CMS quality reporting programs. Today, Joint Commission/CMS common measures and Joint Commission-only measures are used in the CMS Hospital Inpatient Quality Reporting Program, Hospital Outpatient Quality Reporting Program, Hospital Value- Based Purchasing Program, Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program and the Medicare & Medicaid EHR Incentive Program for eligible Hospitals/ Critical Access Hospitals. The Joint Commission-developed hospital-based inpatient psychiatric services (HBIPS) measures were adopted as the initial set of measures for the CMS IPFQR Program with other Joint Commissiondeveloped measures subsequently adopted (i.e., tobacco use treatment and substance use care). Consumers can use Hospital Compare to compare care of local hospitals to state and national averages. Unlike Quality Check, Hospital Compare includes data from Criteria for accountability process measures Research: Strong scientific evidence demonstrates that performing the evidence-based care process improves health outcomes (either directly or by reducing risk of adverse outcomes). Proximity: Performing the care process is closely connected to the patient outcome; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs. Accuracy: The measure accurately assesses whether or not the care process has actually been provided. That is, the measure should be capable of indicating whether the process has been delivered with sufficient effectiveness to make improved outcomes likely. Adverse Effects: Implementing the measure has little or no chance of inducing unintended adverse consequences. 30