Quality Check/Quality Report Glossary of Terms

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A

Accreditation Decisions

The following decisions are effective beginning January 1, 2011.

Accredited is awarded to a health care organization that is in compliance with all standards at the time of the onsite survey or has successfully addressed requirements for improvement in an Evidence of Standards Compliance within 45 or 60 days following the posting of the Accreditation Summary Findings Report.

Provisional Accreditation results when a health care organization fails to successfully address all requirements for improvement in an ESC within 45 or 60 days following the posting of the Accreditation Summary Findings Report. (Prior to 2004 Provisional Accreditation had te same meaning as Preliminary Accreditation described below.)

Accreditation with Follow-up Survey is awarded when a health care organization is not in compliance with specific standards that require a follow-up survey within 30 days to six months. The organization also must successfully address the identified problem area(s) in an ESC submission.

Conditional Accreditation results when a health care organization was previously in Preliminary Denial of Accreditation due to an Immediate Threat to Health or Safety situation; or the organization failed to resolve the requirements of a Provisional Accreditation; or it was not in substantial compliance with the applicable standards, as usually evidenced by a single issue or multiple issues that pose a risk to patient care or safety that was present at the time of survey. The organization must remedy identified problem areas through preparation and submission of Evidence of Standards Compliance and subsequently undergo an onsite, follow-up survey. In addition, an organization may receive Conditional Accreditation for failure to meet certain Joint Commission participation requirements, such as a Periodic Performance Review (PPR) or timely submission of data.

Contingent Accreditation results when a health care organization fails to successfully address all requirements of the Accreditation with Follow-up Survey decision. In most cases, a follow-up survey in 30 days will be required.

Preliminary Denial of Accreditation results when there is justification to deny accreditation to a health care organization due to one or more of the following: an immediate threat to health or safety for patients or the public; failure to resolve the requirements of an Accreditation with Follow-up Survey status after two opportunities to do so; failure to resolve the requirements of a Contingent Accreditation status; or significant noncompliance with Joint Commission standards. This decision is subject to review and appeal before the determination to deny accreditation.

Denial of Accreditation results when a health care organization has been denied accreditation. All review and appeal opportunities have been exhausted.

Preliminary Accreditation results when the health care organization demonstrates compliance with selected standards in the surveys conducted under the Early Survey Policy.

Accreditation With Commendation An accreditation decision awarded to a health care organization that has demonstrated more than satisfactory compliance with applicable Joint Commission standards in all performance areas on a complete accreditation survey.

Accreditation with Full Standards Compliance An accreditation decision awarded to a health care organization that demonstrates satisfactory compliance with applicable Joint Commission standards in all performance areas.

Accreditation with Requirements for Improvement An accreditation decision awarded to a health care organization that demonstrates satisfactory compliance with applicable Joint Commission standards in most performance areas, but has deficiencies in one or more performance areas or in meeting accreditation policy requirements which require resolution within a specified time period.

ACE inhibitors

Medicines that are used to treat heart failure and high blood pressure.  These medicines block an enzyme in the body that is responsible for causing the blood vessels to narrow. If the blood vessels are relaxed, blood pressure is lowered and more oxygen-rich blood can reach the heart.  ACE inhibitors lower the amount of salt and water in the body, which also helps to lower blood pressure.

Activity Date

The Activity Date represents one of the following:  

  1. the end date of an on-site survey, 
  2. the submission date of a required follow-up accreditation activity, or 
  3. the effective date of an administrative accreditation activity.

AMI – Acute Myocardial Infarction

Myocardial Infarction is the proper use of the non-medical term "heart attack".  Myocardial Infarction (abbreviated as "MI") means there is death of some of the muscle cells of the heart as a result of a lack of supply of oxygen and other nutrients. This lack of supply is caused by closure of the artery ("coronary artery") that supplies that particular part of the heart muscle with blood.

Arithmetic Mean

The arithmetic mean is what is commonly called the average.  When the word "mean" is used without a modifier, it can be assumed that it refers to the arithmetic mean.  The mean is the sum of all scores divided by the number of scores.

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B

Benchmark

To measure according to specified standards in order to compare with and improve one's own performance.

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C

Certification Decisions

Certification is awarded after a review to a health care program or service that is in compliance with all standards, uses clinical practice guidelines (applicable to Disease-Specific Care Certification programs only), and meets performance measurement requirements and certification participation requirements at the time of the on-site review; or, if it has not been place in Conditional or Preliminary Denial of Certification status, has successfully addressed all requirements for improvement in an Evidence of Standards Compliance (ESC) within 45 days following the review. If the program or service does not meet these requirements for certification, it will receive one of the following decisions.

Provisional Certification results when a health care program or service fails to do one or more of the following:  1) Successfully address all requirements for improvement in an ESC within 45 days following the review or in a Measures of Success submission. 2) Meet all requirements for the timely submission of data and information to The Joint Commission within 31 days of the due date(s).

Conditional Certification results when a health care program or service fails to do one or both of the following:  1) Be in substantial compliance with the standards, usually determined by the number of not compliant standards that exceed established thresholds at the time of review. The program or service must remedy identified problem areas through preparation and submission of ESC or Measures of Success and a conditional follow-up review. 2) Meet all requirements for the timely submission of data and information to The Joint Commission within 61 days of the due date(s).*

Preliminary Denial of Certification results when there is justification to deny certification to the health care program or service as usually determined by the number of not compliant standards that exceed established thresholds at the time of review. The decision is subject to appeal prior to the determination to deny certification; the appeal process may also result in a decision other than Denial of Certification.

Denial of Certification results when the organization chooses not to appeal or the appeal of a Preliminary Denial of Certification decision is rejected; or a health care program or service does not permit the performance of any review by The Joint Commission; or the program or service fails to do one or more of the following:  1) Meet requirements for the timely submission of data and information to The Joint Commission within 91 days of the due date(s).* 2) Resolve a Conditional Certification status prior to withdrawing from the certification process. 3) Submit payment for review fees or annual fees.

Comparative Agreements

To be eligible for a comparative agreement with the Joint Commission, a accrediting body must demonstrate comparability with the basic threshold criteria, as well as overall comparability with Joint Commission standards, survey process, methods of ensuring surveyor competence, and accreditation policies.

Complementary Agreements

Accrediting organizations that establish complementary agreements with the Joint Commission must also demonstrate comparability with the basic threshold criteria, however, they will not be required to maintain comparability with Joint Commission standards and survey process applicable to the unit, department or service of an organization subject to review.  In most cases, the standards and survey process of these partners are more focused on the technical and clinical aspects of the department or service within a health care organization and are not applicable to the entire organization.

Composite Measure

A measure that combines the results of all process measures with a set into a single rating.

Confidence Interval

A range of values containing the true value of the parameter being estimated with a certain degree of confidence.  The 95% and 99% confidence intervals which have .95 and .99 probabilities of containing the parameter respectively are most commonly used.

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D

Decision Effective Date

The date of the accreditation decision awarded to an organization.

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J

Joint Commission ID Number

The Joint Commission assigns an identification number to each accredited parent organization.

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L

Last Full Survey Date 

The Last Full Survey Date represents the end date of the on-site survey that began the listed program's current accreditation cycle.

Last On-Site Survey Date 

The Last On-Site Survey Date represents the end date of the most recent on-site survey.

LVSD

Left ventricular diastolic dysfunction.  This means a heart chamber is not pumping all blood out before it refills for the next heart beat.  This results in high pressure within the heart and can produce heart failure.

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M

Mortality Rates

30 Day Risk Adjusted Heart Attack Death (Mortality) Rates - Heart Attack Death (Mortality) Rates tell you how the 30-day death rates from heart attack at the hospitals you selected compare to the U.S. National heart attack death (mortality) rate. These comparisons take into account how sick patients were before they were admitted to the hospital and differences in death rates that might be due to chance.

30 Day Risk Adjusted Heart Failure Death (Mortality) Rates - Heart Failure Death (Mortality) Rates tell you how the 30-day death rates from heart failure at the hospitals you selected compare to the U.S. National heart failure death (mortality) rate. These comparisons take into account how sick patients were before they were admitted to the hospital and differences in death rates that might be due to chance.

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N

National Patient Safety Goals

The National Patient Safety Goals are a series of specified actions that accredited organizations are expected to take in order to prevent medical errors.

National Quality Forum

National Quality Forum is a private, not-for-profit membership organization created to develop and implement a national strategy for healthcare quality measurement and reporting. The mission of the NQF is to improve American healthcare through endorsement of consensus-based national standards for measurement and public reporting of healthcare performance data that provide meaningful information about whether care is safe, timely, beneficial, patient-centered, equitable and efficient. Visit NQF online at www.qualityforum.org.

National Quality Improvement Goals

The National Quality Improvement Goals are standardized performance measures that can be applied across accredited health care organizations.  These goals are only currently available for accredited hospitals.  These goals will be reported for other accreditation programs as they become available.

Measure Sets

  1. Children’s Asthma Care:  This category of evidenced based measures assesses the use of indicated treatment for children’s asthma in hospitalized children age 2 through 17 years.
    • Use of Relievers for Inpatient Asthma Overall Rate Age 2 - 17. 
      This measure reports the overall number of pediatric asthma patients age 2 through 17 years who received relievers during hospitalization.  An asthma reliever is a drug that provides relief from asthma symptoms.
    • Use of Systemic Corticosteroids for Inpatient Asthma Overall Rate Age 2 - 17
      This measure reports the overall number of pediatric asthma patients age 2 through 17 years who received systemic corticosteroids during hospitalization.   A systemic corticosteroid is a medication used to reduce airway inflammation and control moderate to severe asthma symptoms.
    • Children’s Asthma Care Age 2 - 4
      Overall report on use of indicated treatment for children’s asthma in hospitalized children age 2 through 4 years.  Indicated treatment for children’s asthma includes relievers and systemic corticosteroids.
      • Use of relievers for inpatient asthma Age 2 - 4
        This measure reports the number of pediatric asthma patients age 2 through 4 years who received relievers during hospitalization.  An asthma reliever is a drug that provides relief from asthma symptoms.
      • Use of systemic corticosteroids for inpatient asthma.Age 2 - 4
        This measure reports the number of pediatric asthma patients age 2 through 4 years who received systemic corticosteroids during hospitalization.  A systemic corticosteroid is a medication used to reduce airway inflammation and control moderate to severe asthma symptoms.
    • Children’s Asthma Care Age 5 - 12
      Overall report on use of indicated treatment for children’s asthma in hospitalized children age 5 through 12 years.  Indicated treatment for children’s asthma includes relievers and systemic corticosteroids.
      • Use of relievers for inpatient asthma Age 5 - 12
        This measure reports the number of pediatric asthma patients age 5 through 12 years who received relievers during hospitalization.  An asthma reliever is a drug that provides relief from asthma symptoms.
      • Use of systemic corticosteroids for inpatient asthma Age 5 - 12
        This measure reports the number of pediatric asthma patients age 5 through 12 years who received systemic corticosteroids during hospitalization.  A systemic corticosteroid is a medication used to reduce airway inflammation and control moderate to severe asthma symptoms.
    • Children’s Asthma Care Age 13 - 17
      Overall report on use of indicated treatment for children’s asthma in hospitalized children age 13 through 17 years.  Indicated treatment for children’s asthma includes relievers and systemic corticosteroids.
      • Use of relievers for inpatient asthma Age 13 - 17
        This measure reports the number of pediatric asthma patients age 13 through 17 years who received relievers during hospitalization.  An asthma reliever is a drug that provides relief from asthma symptoms.
      • Use of systemic corticosteroids for inpatient asthma Age 13 - 17
        This measure reports the number of pediatric asthma patients age 13 through 17 years who received systemic corticosteroids during hospitalization.  A systemic corticosteroid is a medication used to reduce airway inflammation and control moderate to severe asthma symptoms.

      • Use of systemic corticosteroids for inpatient asthma Age 13 - 17
        This measure reports the number of pediatric asthma patients age 13 through 17 years who received systemic corticosteroids during hospitalization.  A systemic corticosteroid is a medication used to reduce airway inflammation and control moderate to severe asthma symptoms.

  2. Hospital-Based Inpatient Psychiatric Services:  This category of evidenced based measures assesses the overall quality of care given to psychiatric patients.
    • Hours of Physical Restraint Use Overall Rate. 
      This measure reports the total hours patients were kept in physical restraints for every 1,000 hours of patient care. Physical restraint is any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely when it is used as a restriction to manage a patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition.
      • Hours of Physical Restraint Use Children Age 1 - 12
        This is a ratio measure. This measure reports the number of hours patients age 1 through 12 years were kept in physical restraints for every 1,000 hours of patient care. Physical restraint is any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely when it is used as a restriction to manage a patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition.
      • Hours of Physical Restraint Use Adolescents Age 13 - 17
        This is a ratio measure. This measure reports the number of hours patients age 13 through 17 years were kept in physical restraints for every 1,000 hours of patient care. Physical restraint is any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely when it is used as a restriction to manage a patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition.
      • Hours of Physical Restraint Use Adults Age 18 - 64
        This is a ratio measure. This measure reports the number of hours patients age 18 through 64 years were kept in physical restraints for every 1,000 hours of patient care. Physical restraint is any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely when it is used as a restriction to manage a patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition.
      • Hours of Physical Restraint Use Older Adults Age 65 and Older
        This is a ratio measure. This measure reports the number of hours patients age 65 and older were kept in physical restraints for every 1,000 hours of patient care. Physical restraint is any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely when it is used as a restriction to manage a patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition.
    • Hours of Seclusion Use Overall Rate. 
      This measure reports the total hours patients were kept in physical restraints for every 1,000 hours of patient care. Physical restraint is any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely when it is used as a restriction to manage a patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition.
      • Hours of Seclusion Use Children Age 1 - 12
        This is a ratio measure. This measure reports the number of hours patients age 1 through 12 years were kept in seclusion for every 1,000 hours of patient care. Seclusion is the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving.
      • Hours of Seclusion Use Adolescents Age 13 - 17
        This is a ratio measure. This measure reports the number of hours patients age 13 through 17 years were kept in seclusion for every 1,000 hours of patient care. Seclusion is the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving.
      • Hours of Seclusion Use Adults Age 18 - 64
        This is a ratio measure. This measure reports the number of hours patients age 18 through 64 years were kept in seclusion for every 1,000 hours of patient care. Seclusion is the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving.
      • Hours of Seclusion Use Older Adults Age 65 and Older
        This is a ratio measure. This measure reports the number of hours patients age 65 and older were kept in seclusion for every 1,000 hours of patient care. Seclusion is the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving.
    • Patients Discharged on Multiple Antipsychotic Medications Overall Rate 
      This measure reports the overall number of patients discharged on two or more antipsychotic medications. Antipsychotic medications are a group of drugs used to treat psychosis. Psychosis is a mental illness that markedly interferes with a person's capacity to meet life's everyday demands.
      • Patients Discharged on Multiple Antipsychotic Medications Children Age 1 - 12
        This is a ratio measure. This measure reports the number of patients age 1 through 12 years discharged on two or more antipsychotic medications. Antipsychotic medications are a group of drugs used to treat psychosis. Psychosis is a mental illness that markedly interferes with a person's capacity to meet life's everyday demands.
      • Patients Discharged on Multiple Antipsychotic Medications Adolescents Age 13 - 17
        This is a ratio measure. This measure reports the number of patients age 13 through 17 years discharged on two or more antipsychotic medications. Antipsychotic medications are a group of drugs used to treat psychosis. Psychosis is a mental illness that markedly interferes with a person's capacity to meet life's everyday demands.
      • Patients Discharged on Multiple Antipsychotic Medications Adults Age 18 - 64
        This is a ratio measure. This measure reports the number of patients age 18 through 64 years discharged on two or more antipsychotic medications. Antipsychotic medications are a group of drugs used to treat psychosis. Psychosis is a mental illness that markedly interferes with a person's capacity to meet life's everyday demands.
      • Patients Discharged on Multiple Antipsychotic Medications Older Adults Age 65 and Older
        This is a ratio measure. This measure reports the number of patients age 65 and older discharged on two or more antipsychotic medications. Antipsychotic medications are a group of drugs used to treat psychosis. Psychosis is a mental illness that markedly interferes with a person's capacity to meet life's everyday demands.
    • Multiple Antipsychotic Medications at Discharge with Appropriate Justification Overall Rate 
      This measure reports the number of patients discharged on two or more antipsychotic medications for which there was an appropriate justification. Antipsychotic medications are a group of drugs used to treat psychosis. Psychosis is a mental illness that markedly interferes with a person's capacity to meet life's everyday demands. Appropriate justifications include previous attempts to control psychosis with one antipsychotic medication, a plan to reduce the number of antipsychotic medications to one antipsychotic medication or the addition of an antipsychotic medication when the patient is also being treated with Clozapine.
      • Multiple Antipsychotic Medications at Discharge with Appropriate Justification Children Age 1 - 12
        This is a ratio measure. This measure reports the number of patients age 1 through 12 years discharged on two or more antipsychotic medications for which there was an appropriate justification. Antipsychotic medications are a group of drugs used to treat psychosis. Psychosis is a mental illness that markedly interferes with a person's capacity to meet life's everyday demands. Appropriate justifications include previous attempts to control psychosis with one antipsychotic medication, a plan to reduce the number of antipsychotic medications to one antipsychotic medication or the addition of an antipsychotic medication when the patient is also being treated with Clozapine.
      • Multiple Antipsychotic Medications at Discharge with Appropriate Justification Adolescents Age 13 - 17
        This is a ratio measure. This measure reports the number of patients age 13 through 17 years discharged on two or more antipsychotic medications for which there was an appropriate justification. Antipsychotic medications are a group of drugs used to treat psychosis. Psychosis is a mental illness that markedly interferes with a person's capacity to meet life's everyday demands. Appropriate justifications include previous attempts to control psychosis with one antipsychotic medication, a plan to reduce the number of antipsychotic medications to one antipsychotic medication or the addition of an antipsychotic medication when the patient is also being treated with Clozapine.
      • Multiple Antipsychotic Medications at Discharge with Appropriate Justification Adults Age 18 - 64
        This is a ratio measure. This measure reports the number of patients age 18 through 64 years discharged on two or more antipsychotic medications for which there was an appropriate justification. Antipsychotic medications are a group of drugs used to treat psychosis. Psychosis is a mental illness that markedly interferes with a person's capacity to meet life's everyday demands. Appropriate justifications include previous attempts to control psychosis with one antipsychotic medication, a plan to reduce the number of antipsychotic medications to one antipsychotic medication or the addition of an antipsychotic medication when the patient is also being treated with Clozapine.
      • Multiple Antipsychotic Medications at Discharge with Appropriate Justification Older Adults Age 65 and Older
        This is a ratio measure. This measure reports the number of patients age 65 and older discharged on two or more antipsychotic medications for which there was an appropriate justification. Antipsychotic medications are a group of drugs used to treat psychosis. Psychosis is a mental illness that markedly interferes with a person's capacity to meet life's everyday demands. Appropriate justifications include previous attempts to control psychosis with one antipsychotic medication, a plan to reduce the number of antipsychotic medications to one antipsychotic medication or the addition of an antipsychotic medication when the patient is also being treated with Clozapine.
    • Post Discharge Continuing Care Plan Created Overall Rate  
      This measure reports the overall number of patients discharged with a continuing care plan created. A continuing care plan is information for the next provider of care which contains the reason the patient was hospitalized, the patient’s diagnosis at the time of discharge from the hospital, the list of all medications the patient was prescribed at the time of discharge from the hospital and the recommendations for the patient’s continued care at the time of discharge from the hospital. The next provider of care is the medical professional or facility who will be responsible for managing the patient’s medications and treatment after discharge from the hospital.
      • Post Discharge Continuing Care Plan Created Children Age 1 - 12
        This is a ratio measure. This measure reports the number of patients age 1 through 12 years discharged with a continuing care plan created. A continuing care plan is information for the next provider of care which contains the reason the patient was hospitalized, the patient’s diagnosis at the time of discharge from the hospital, the list of all medications the patient was prescribed at the time of discharge from the hospital and the recommendations for the patient’s continued care at the time of discharge from the hospital. The next provider of care is the medical professional or facility who will be responsible for managing the patient’s medications and treatment after discharge from the hospital.
      • Post Discharge Continuing Care Plan Created Adolescents Age 13 - 17
        This is a ratio measure. This measure reports the number of patients age 13 through 17 years discharged with a continuing care plan created. A continuing care plan is information for the next provider of care which contains the reason the patient was hospitalized, the patient’s diagnosis at the time of discharge from the hospital, the list of all medications the patient was prescribed at the time of discharge from the hospital and the recommendations for the patient’s continued care at the time of discharge from the hospital. The next provider of care is the medical professional or facility who will be responsible for managing the patient’s medications and treatment after discharge from the hospital.
      • Post Discharge Continuing Care Plan Created Adults Age 18 - 64
        This is a ratio measure. This measure reports the number of patients age 18 through 64 years discharged with a continuing care plan created. A continuing care plan is information for the next provider of care which contains the reason the patient was hospitalized, the patient’s diagnosis at the time of discharge from the hospital, the list of all medications the patient was prescribed at the time of discharge from the hospital and the recommendations for the patient’s continued care at the time of discharge from the hospital. The next provider of care is the medical professional or facility who will be responsible for managing the patient’s medications and treatment after discharge from the hospital.
      • Post Discharge Continuing Care Plan Created Older Adults Age 65 and Older
        This is a ratio measure. This measure reports the number of patients age 65 and older years discharged with a continuing care plan created. A continuing care plan is information for the next provider of care which contains the reason the patient was hospitalized, the patient’s diagnosis at the time of discharge from the hospital, the list of all medications the patient was prescribed at the time of discharge from the hospital and the recommendations for the patient’s continued care at the time of discharge from the hospital. The next provider of care is the medical professional or facility who will be responsible for managing the patient’s medications and treatment after discharge from the hospital.
    • Post Discharge Continuing Care Plan Transmitted Overall Rate 
      This measure reports the overall number of patients discharged with a continuing care plan provided to the next provider of care within 5 days of the patient’s discharge. A continuing care plan is information for the next provider of care which contains the reason the patient was hospitalized, the patient’s diagnosis at the time of discharge from the hospital, the list of all medications the patient was prescribed at the time of discharge from the hospital and the recommendations for the patient’s continued care at the time of discharge from the hospital. The next provider of care is the medical professional or facility who will be responsible for managing the patient’s medications and treatment after discharge from the hospital.
      • Post Discharge Continuing Care Plan Transmitted Children Age 1 - 12
        This is a ratio measure. This measure reports the number of patients age 1 through 12 years discharged with a continuing care plan provided to the next provider of care within 5 days of the patient’s discharge. A continuing care plan is information for the next provider of care which contains the reason the patient was hospitalized, the patient’s diagnosis at the time of discharge from the hospital, the list of all medications the patient was prescribed at the time of discharge from the hospital and the recommendations for the patient’s continued care at the time of discharge from the hospital. The next provider of care is the medical professional or facility who will be responsible for managing the patient’s medications and treatment after discharge from the hospital.
      • Post Discharge Continuing Care Plan Transmitted Children Adolescents Age 13 - 17
        This is a ratio measure. This measure reports the number of patients age 13 through 17 years discharged with a continuing care plan provided to the next provider of care within 5 days of the patient’s discharge. A continuing care plan is information for the next provider of care which contains the reason the patient was hospitalized, the patient’s diagnosis at the time of discharge from the hospital, the list of all medications the patient was prescribed at the time of discharge from the hospital and the recommendations for the patient’s continued care at the time of discharge from the hospital. The next provider of care is the medical professional or facility who will be responsible for managing the patient’s medications and treatment after discharge from the hospital.
      • Post Discharge Continuing Care Plan Transmitted Children Adults Age 18 - 64
        This is a ratio measure. This measure reports the number of patients age 18 through 64 years discharged with a continuing care plan provided to the next provider of care within 5 days of the patient’s discharge. A continuing care plan is information for the next provider of care which contains the reason the patient was hospitalized, the patient’s diagnosis at the time of discharge from the hospital, the list of all medications the patient was prescribed at the time of discharge from the hospital and the recommendations for the patient’s continued care at the time of discharge from the hospital. The next provider of care is the medical professional or facility who will be responsible for managing the patient’s medications and treatment after discharge from the hospital.
      • Post Discharge Continuing Care Plan Transmitted Older Adults Age 65 and Older
        This is a ratio measure. This measure reports the number of patients age 65 and older discharged with a continuing care plan provided to the next provider of care within 5 days of the patient’s discharge. A continuing care plan is information for the next provider of care which contains the reason the patient was hospitalized, the patient’s diagnosis at the time of discharge from the hospital, the list of all medications the patient was prescribed at the time of discharge from the hospital and the recommendations for the patient’s continued care at the time of discharge from the hospital. The next provider of care is the medical professional or facility who will be responsible for managing the patient’s medications and treatment after discharge from the hospital.
  3. Heart Attack Care:  This category of evidence based measures assesses the overall quality of care provided to Heart Attack (AMI) patients.
    • ACE inhibitor or ARB for LVSD *
      Heart attack patients who receive either a prescription for a medicine called an "ACE inhibitor" or a medicine called an angiotensin receptor blocker (ARB) when they are discharged from the hospital.  This measure reports what percent of heart attack patients who have problems with the heart pumping enough blood to the body were prescribed medicines to improve the heart's ability to pump blood.
    • Adult smoking cessation advice/counseling
      Heart attack patients who are given advice about stopping smoking while they are in the hospital.  This measure reports what percent of adult heart attack patients are provided advice and/or counseling to quit smoking.  Smoking harms the heart, lungs and blood vessels and makes existing heart disease worse.
    • Aspirin at Arrival *
      Heart attack patients receiving aspirin when arriving at the hospital.  This measure reports what percent of heart attack patients receive aspirin within 24 hours before or after they arrive at the hospital.  Aspirin is beneficial because it reduces the tendency of blood to clot in blood vessels of the heart and improves survival rates.
    • Aspirin prescribed at discharge*
      Heart attack patients who receive a prescription for aspirin when being discharged from the hospital.  This measure reports how often aspirin was prescribed to heart attack patients when they are leaving a hospital.  Aspirin is beneficial because it reduces the tendency of blood to clot in blood vessels of the heart and improves survival rates.
    • Beta blocker at arrival *
      Heart attack patients who receive a medicine called a "beta blocker" when they arrive at the hospital.  This measure reports what percent of heart attack patients - within 24 hours after arrival were prescribed a special type of medicine that reduces heart damage.
    • Beta blocker prescribed at discharge *
      Heart attack patients who have a medicine called a "beta blocker" prescribed when they are discharged from the hospital.  This measure reports what percent of heart attack patients were prescribed a special type of medicine when leaving the hospital, that has been shown to reduce further heart damage.
    • Inpatient mortality
      Death of a patient with a heart attack during a hospital stay.  This measure reports heart attack patients who die during their hospital stay.  This measure accounts for the fact that some patients are sicker or have other preexisting conditions that make death more likely.  This is called "risk adjustment."
    • PCI Received Within 120 Minutes of Hospital Arrival
      Heart attack patient with a clogged artery in the heart that is opened with a balloon therapy called PCI within 120 minutes of hospital arrival.  This measure reports how quickly heart attack patients had a clogged artery in the heart opened with a balloon therapy called PCI to increase blood flow to the heart and reduce heart damage. Lack of blood supply to heart muscle can cause lasting heart damage. In certain types of heart attacks, a small balloon is threaded into a blood vessel in the heart to open up a clogged artery that keeps the blood from flowing to the heart muscle.  It is important that this therapy be given quickly after a heart attack is diagnosed.
    • Thrombolytic Agent Received Within 30 Minutes of Hospital Arrival
      Heart Attack patients who receive a medicine that breaks up blood clots (thrombolytic therapy) within 30 minutes of hospital arrival.  This measure reports how quickly heart attack patients were given a medication that breaks up blood clots (Thrombolytic therapy). Breaking up blood clots increases blood flow to the heart.  If blood flow is returned to the heart muscle quickly during a heart attack, the risk of death is decreased.  The medicine that breaks up clots in the arteries and allows the return of normal blood flow is called Thrombolytic therapy and is used in certain types of heart attacks.  It is important that this medicine be given quickly after a heart attack is diagnosed.
    • Time to PCI
      Length of time before a clogged artery in the heart is opened with a balloon therapy called PCI.  Lack of blood supply to heart muscle can cause lasting heart damage. In certain types of heart attacks, a small balloon is threaded into a blood vessel in the heart to open up a clogged artery that keeps the blood from flowing to the heart muscle.  It is important that this therapy be given quickly after a heart attack is diagnosed. 
    • Time to thrombolysis
      Length of time before a medicine that breaks up blood clots (thrombolytic therapy) is given.  If blood flow is returned to the heart muscle quickly during a heart attack, the risk of death is decreased.  The medicine that breaks up clots in the arteries and allows the return of normal blood flow is called thrombolytic therapy and is used in certain types of heart attacks.  It is important that this medicine be given quickly after a heart attack is diagnosed.

  4. Heart Failure Care:  This category of evidence based measures assesses the overall quality of care provided to Heart Failure (HF) patients.
    • ACE inhibitor or ARB for LVSD *
      Heart attack patients who receive either a prescription for a medicine called an "ACE inhibitor" or a medicine called an angiotensin receptor blocker (ARB) when they are discharged from the hospital.  This measure reports what percent of heart attack patients who have problems with the heart pumping enough blood to the body were prescribed medicines to improve the heart's ability to pump blood.
    • Adult smoking cessation advice/counseling
      Heart failure patients who are given advice about stopping smoking while they are in the hospital.  This measure reports what percent of adult heart failure patients are provided advice and/or counseling to quit smoking.  Smoking harms the heart, lungs and blood vessels and makes existing heart disease worse.
    • Discharge Instructions
      Heart failure patients who receive specific discharge instructions about their condition.  This measure reports what percent of patients with heart failure are given information about their condition and care when they leave the hospital.  Patient education about medicines, diet, activities, and signs to watch for is important in order to prevent further hospitalization.
    • LVF assessment *
      Heart failure patients who have had the function of the main pumping chamber of the heart (i.e., left ventricle) checked during their hospitalization.  This measure reports what percent of patients with heart failure receive an in-depth evaluation of heart muscle function in order to get the right treatment for their heart failure.

  5. Immunization (IMM)
    • Pneumococcal Immunization (PPV23)
      This prevention measure assesses pneumococcal vaccine screening and immunization for all defined categories of acute care hospitalized inpatients
    • Pneumococcal Immunization (PPV-23) – High Risk Populations (Age 6-64 years
      This prevention measure assesses pneumococcal vaccine screening and immunization, when indicated, for acute care hospitalized inpatients aged between 6 and 64 years who are considered high risk.
    • Pneumococcal Immunization (PPV23) – Age 65 and Older
      This prevention measure assesses pneumococcal vaccine screening and immunization, when indicated, for acute care hospitalized inpatients 65 years of age and older.
    • Influenza Immunization (Seasonal Measure)
      This prevention measure addresses acute care hospitalized inpatients age 6 months and older who were screened for seasonal influenza immunization status and were vaccinated prior to discharge, if indicated.


  6. Pneumonia (PN):  This category of evidence based measures assesses the overall quality of care provided to Pneumonia patients.
    • Adult smoking cessation advice/counseling
      Pneumonia patients who are given advice about stopping smoking while they are in the hospital.  This measure reports what percent of adult pneumonia patients are provided advice and/or counseling to quit smoking.  Smoking harms the heart, lungs and blood vessels and makes existing disease worse.
    • Antibiotic timing
      Length of time from arrival at the hospital until antibiotics are given.  This measure reports how long a pneumonia patient was in the hospital before they were given antibiotics.  Antibiotics are generally given as soon as possible to pneumonia patients to speed their recovery.
    • Blood cultures for pneumonia patients admitted through the Emergency Department *
      Pneumonia patients who were admitted through the Emergency Department who had a blood test in the Emergency Department for the presence of bacteria in their blood.  Before antibiotics are given, blood samples are taken to test for the type of infection. This measure reports the percent of pneumonia patients admitted through the Emergency Department who received this test before antibiotics were given.
    • Blood cultures for pneumonia patients in intensive care units
      Pneumonia patients cared for in an intensive care unit that had a blood test for the presence of bacteria in their blood within 24 hours of hospital arrival.  This measure reports the percent of pneumonia patients in intensive care units who had a blood culture within 24 hours prior to or after hospital arrival.
    • Initial Antibiotic Received Within 8 Hours of Hospital Arrival
      Pneumonia patients who are given an antibiotic within 8 hours of arriving at the hospital. This measure reports the percent of adult pneumonia patients who are given an antibiotic within 8 hours or arriving at the hospital.
    • Initial Antibiotic Received Within 4 Hours of Hospital Arrival
      Pneumonia patients who are given an antibiotic within 4 hours of arriving at the hospital.  This measure reports the percent of adult pneumonia patients who are given an antibiotic within 4 hours or arriving at the hospital.
    • Initial Antibiotic Selection for CAP in Immunocompetent – ICU Patient
      Patients in intensive care units who have Community-Acquired Pneumonia who received the appropriate medicine (antibiotic) that has been shown to be effective for Community-Acquired Pneumonia.  This measure reports how often patients in intensive care units with Community-Acquired Pneumonia were given the correct antibiotic within 24 hours of hospital arrival, based on recommendations from written guidelines, for the treatment of pneumonia.
    • Initial Antibiotic Selection for CAP in Immunocompetent – Non ICU Patient
      Patients not in intensive care units who have Community-Acquired Pneumonia who received the appropriate medicine (antibiotic) that has been shown to be effective for Community-Acquired Pneumonia.  This measure reports how often patients with Community-Acquired Pneumonia not cared for in intensive care units, were given the correct antibiotic within 24 hours of hospital arrival, based on recommendations from written guidelines, for the treatment of pneumonia.
    • Influenza Vaccination
      Pneumonia patients in the hospital during flu season (October through February) who were given the influenza vaccination prior to leaving the hospital.  This measure reports how often pneumonia patients in the hospital during the flu season were given flu vaccine if needed, prior to leaving the hospital
    • Oxygenation assessment *
      Patients with pneumonia in which the amount of oxygen in the bloodstream was measured.  This measure reports how many patients with pneumonia had their blood/oxygen level measured.  Pneumonia reduces the amount of oxygen carried in a patient's blood. 
    • Pneumococcal vaccination *
      Pneumonia vaccination.  This measure reports how many patients 65 years and older were screened and vaccinated to prevent pneumonia.

  7. Pregnancy and Related Conditions:  This category of evidence based measures assesses the overall quality of care provided to pregnant patients.
    • Inpatient neonatal mortality
      This measure reports how often infants died before 28 days of birth.  This measure is adjusted to reflect the fact that some babies are sicker than others at or shortly after birth.
    • Third or fourth degree laceration
      Vaginal tears during delivery.  This measure reports how often patients have significant tears between the vagina and anus while having a baby.  These types of tears can lead to other medical complications.
    • Vaginal birth after a Cesarean delivery (VBAC)
      This measure reports how often patients had a vaginal birth after previously having a Cesarean section.

  8. Surgical Infection Prevention Care:  This category of evidence based measures assesses the overall use of indicated antibiotics for surgical infection prevention.
    • Patients having a surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.
      This measure reports how often patients having surgery received medicine that prevents infection (an antibiotic) within one hour before the skin was surgically cut.  Infection is lowest when patients receive antibiotics to prevent infection within one hour before the skin is surgically cut.  Note: Not every surgery requires antibiotics and this measure reports on those selected surgeries where evidence/experts have identified that antibiotics would be helpful.
    • Patients having surgery who received the appropriate medicine (antibiotic) which is shown to be effective for the type of surgery performed.
      This measure reports how often patients who had surgery were given the appropriate medicine (antibiotic) that prevents infection which is know to be effective for the type of surgery, based upon the recommendations of experts around the country. Note: Not every surgery requires antibiotics and this measure reports on those selected surgeries where evidence/experts have identified that antibiotics would be helpful.
    • Patients who had surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.
      This measure reports how often surgery patients whose medicine (an antibiotic) to prevent infection was stopped within 24 hours after the surgery ended.  Giving medicine that prevents infection for more than 24 hours after the end of surgery is not helpful, unless there is a specific reason (for example, fever or other signs of infection). Note: Not every surgery requires antibiotics and this measure reports on those selected surgeries where evidence/experts have identified that antibiotics would be helpful.
      • Patients Having Blood Vessel Surgery
        Overall report of hospital's performance on Surgical Infection Prevention Measure for Blood Vessel Surgery
      • Patients Having Colon/Large Intestine Surgery
        Overall report of hospital's performance on Surgical Infection Prevention Measures for Colon/Large Intestine Surgery
      • Patients Having Coronary Artery Bypass Graft Surgery
        Overall report of hospital's performance on Surgical Infection Prevention Measures for Coronary Artery Bypass Graft Surgery
      • Patients Having Hip Joint Replacement Surgery
        Overall report of hospital's performance on Surgical Infection Prevention Measures for Hip Joint Replacement Surgery
      • Patients Having a Hysterectomy
        Overall report of hospital's performance on Surgical Infection Prevention Measure for Hysterectomy Surgery
      • Patients Having Knee Joint Replacement Surgery
        Overall report of hospital's performance on Surgical Infection Prevention Measures for Knee Joint Replacement Surgery
      • Patients Having Open Heart Surgery other than Coronary Artery Bypass Graft
        Overall report of hospital's performance on Surgical Infection Prevention Measures for Open Heart Surgery

*   This information can also be viewed at www.hospitalcompare.hhs.gov.

National Quality Improvement Goals Footnotes

  1. The measure or measure set is not reported.
    In 2004, hospitals provide measure results for two of the four approved measure sets. If the measure set displayed has not been selected by the hospital for reporting, this footnote will be provided. Some hospitals may not provide a specific procedure reported by a measure. If the hospital does not provide the procedure, the measure information is not collected and this footnote will be provided.
  2. The measure set does not have an overall result.
    The Joint Commission collects information on several different types of measures.  Process measures are reported as percentages and reflect how often the type of care was done. Process measure results are totaled for a measure set to determine the measure set result. Some measure sets such as Pregnancy Care do not contain process measures. For measure sets without process measures no overall measure set result is calculated.
  3. The number is not enough for comparison purposes.
    The Joint Commission has established minimum amount of patients for comparative results to be calculated. A minimum number of patients are used to establish that the measure result is representative of the type of care a patient can expect at the hospital.
  4. The measure meets the Privacy Disclosure Threshold rule.
    The Privacy Disclosure Threshold rule is used to limit the possibility of disclosing identifying information about patients. If the eligible number of patients is less than 3,
    the measure results are suppressed.
  5. The organization scored above 90% but was below most other organizations.
    The results of some measures are very high. For example, all hospitals are very good at providing aspirin at arrival for heart attack patients. Very high overall scores for a measure can result in a hospital having a "minus" for the measure even though its measure result is above 90%.
  6. The measure results are not statistically valid.
    The Joint Commission reviews the National Quality Improvement Goal measure results provided by the accredited hospitals. If the results are potentially in error due to the range of values submitted, the measure results are not used.
  7. The results are based on a sample of patients.
    Hospitals with a very large number of patients do not have to submit information on every patient treated. The hospital can submit a sample of the patients as the sample accurately represents the result for that measure. When a hospital submits a sample to represent its performance this footnote is provided.
  8. The number of months with measure data are below the reporting requirement.
    Hospitals must have nine months of data in order for an organizations data to be displayed. 
  9. The measure results are temporarily suppressed pending resubmission of updated data.
    The measure results are being suppressed temporarily pending resubmission of updated measure values that will be reflected in the next quarterly posting of the National Quality Improvement Goals.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.

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PCI

Coronary angioplasty, sometimes called PTCA is a procedure performed by a heart doctor in order to open up a blocked artery of the heart and restore blood flow to the heart muscle. Angioplasty is used as an alternative treatment to coronary artery bypass surgery.

Primary Care Medical Home

A model of organizing primary care that encompasses being patient-centered, comprehensive care, coordinated care, superb access to care and a systems-based approach to quality and safety.

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Scoring for the National Quality Improvement Goals

Each National Quality Improvement Goal contains certain measures that organizations must do meet the goal.  For example, one measure for Heart Attack Care is giving patients an aspirin at arrival.

  • Nationwide Top 10% Scored at Least
    The number of times, as a percentage, the top 10% of all Joint Commission accredited hospitals in the nation followed the recommended treatment/procedure during the time period being reported.
  • Nationwide Average Rate
    The average rate for all healthcare organizations in the nation that provide results for a measure.  The average rate is calculated by dividing the total number of patients who had 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 nation for the timeframe being reported.
  • Statewide Top 10% Scored at Least
    The number of times, as a percentage, the top 10% of all Joint Commission accredited hospitals in the state followed the recommended treatment/procedure during the time period being reported.
  • Statewide Average Rate
    The average rate for all healthcare organizations in the state that provide results for a measure.  The average rate is calculated by dividing the total number of patients who had 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 for the timeframe being reported.
  • Nationwide Top 10% Scored at Most
    For continuous variable timing measures, this represents the median time where the lower 10% of all Joint Commission accredited hospitals in the nation scored for the recommended treatment/procedure during the time period being reported.
  • Nationwide Weighted Median
    For continuous variable timing measures, this represents the average median time weighted by the number of patients who had the recommended care provided to them who met the inclusion and exclusion criteria of all Joint Commission accredited hospitals in the nation during the time period reported.
  • Statewide Top 10% Scored at Most
    For continuous variable timing measures, this represents the median time where the lower 10% of all Joint Commission accredited hospitals in the state scored for the recommended treatment/procedure during the time period being reported.
  • Statewide Weighted Median
    For continuous variable timing measures, this represents the average median time weighted by the number of patients who had the recommended care provided to them who met the inclusion and exclusion criteria of the measure of all Joint Commission accredited hospitals in the state during the time period reported.

Special Quality Awards

A merit badge recognizes achievement by a health care organization that goes above and beyond accreditation. Merit badges must be national in scope, and relate to the delivery of high quality health care, and be awarded by an organization that is an established and credible advocate for improvements in health care.

ACS Bariatric Surgery Center Network Accreditation Program:
To improve quality and facilitate access to care for morbidly obese patients, the American College of Surgeons Bariatric Surgery Center Network (ACS BSCN) Accreditation Program recognizes as Bariatric Centers, facilities which implement and maintain certain physical resources, human resources, standards of practice, and documentation of outcomes of care.  

The ACS BSCN delineates standards for five levels of inpatient facilities as well as standards for two levels of outpatient surgical care.

  • Level 1a and 1b - Bariatric centers which provide complete care devoted to bariatric surgery. These hospitals manage the most challenging and complex patients with optimal opportunity for safe and effective outcomes.  They have high volume practices conducted by professional services of breadth and depth.
  • Level 2a, 2b, and 2-New - These centers will provide high quality care to a lower volume of patients having lesser obesity and lesser comorbidities.
  • Outpatient and Outpatient-New - Surgery centers for the application and adjustment of laparoscopic gastric band. These outpatient surgical centers will provide high-quality surgical care devoted to bariatric surgery.

American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP):
The ACS NSQIP is a nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care.  Hospitals participating in this program are involved in the following key components relating to improving the quality of surgical care:

  1. Data Collection
  2. Data Monitoring and Validation
  3. Report Generation
  4. Data Analysis
  5. Focus on Systems
  6. Feedback

American Health Care Association (AHCA)/ National Center for Assisted Living (NCAL) Quality Award:
Recognizes AHCA/NCAL member organizations which demonstrate their commitment to continuous quality improvement.  This award is based on the core values and criteria of the Malcolm Baldrige National Quality Award (MBNQA). The Quality Award Program has three progressive step levels. Facilities must achieve an award at each level to progress to the next level:

Bronze – Commitment to Quality (formerly Step I)  Applicants begin their quality journey by developing an organizational profile including vision and mission statement, an awareness of their environment and customers’ expectations, and a demonstration of their ability to improve a process.
 
Silver – Achievement in Quality (formerly Step II) Applicants demonstrate a level of achievement in their quality journey through good performance outcomes that have evolved from how they embrace the core values and concepts of visionary leadership, focus on the future, resident-focused excellence, management by innovation, and focus on results and creating value.

Gold – Excellence in Quality (formerly Step III) Applicants must show superior performance over time that is based on their systematic approaches to leadership; strategic planning, focus on customers, measurement, analysis and knowledge management, workforce focus, process management and results.  Gold applicants address the complete Baldrige Criteria for Performance Excellence in Health Care.  Only those facilities that won Silver (Step II) awards in previous years may apply.

The American Hospital Quest for Quality Prize:
Is an American Hospital Association Award that honors leadership and innovation in quality, safety, and commitment to patient care by hospitals and / or multi-hospital health systems.  This award has been established to:

  • "Raise awareness of the need for an organizational commitment to patient safety and quality.
  • Reward successful patient safety efforts, particularly in the development of a culture of safety.
  • Inspire organizations to increase their patient safety efforts
    Communicate successful programs and strategies to the industry.

The award winner receives a $75,000 prize, two finalists receive $12,500 each; other hospitals may be recognized with Citations of Merit.

The American Society for Metabolic and Bariatric Surgery (ASMBS) Bariatric Surgery Centers of Excellence® (BSCOE) program, endorsed by the Centers for Medicare and Medicaid Services (CMS) and other health insurers, is a rigorous evaluation process to identify facilities and surgeons that have a comprehensive program and meet established program requirements for providing safe bariatric surgical care. Applicants undergo a site inspection which not only documents process, i.e., equipment, supplies, training of surgeons and staff and the availability of consultant services — but emphasizes results. To learn more visit http://www.surgicalreview.org/

Cheers Award:
Is presented by The Institute for Safe Medication Practices (ISMP) to recognize individuals, health care organizations, regulatory agencies, professional organizations, researchers, pharmaceutical and other health care related businesses that have set a superlative standard of excellence in the prevention of medication errors during the award year. 

Department of Veterans Affairs National Surgical Quality Improvement Program (VA NSQIP):
The VA NSQIP is the first nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care.  VA hospitals participating in this program are involved in the following key components relating to improving the quality of surgical care:

  1. Data Collection
  2. Data Monitoring and Validation
  3. Report Generation
  4. Data Analysis
  5. Focus on Systems
  6. Feedback

Urgent Care Association of America Certification:
The Certified Urgent Care program was created in 2009 to answer the question: What defines an urgent care center? Urgent Care facilities with the CUC designation have: 

  1. Mark of Distinction to educate your community and stakeholders and eliminate confusion with other kinds of providers
  2. A Tool for Negotiation to provide a national benchmark for discussing higher fee schedules
  3. An Edge in Marketing to clearly and effectively describe your level of services

Ernest Amory Codman Award:
Presented by the Joint Commission, recognizes achievement by organizations and individuals in the use of process and outcomes measures to improve organization performance and quality of care. 

Franklin Award of Distinction:
Honors a case management system that demonstrates excellence in building collaboration among the various professional and technical staff in the hospital to focus on case management and performance measurement results having a positive effect on patient care.

Get With The Guidelines(SM):
The American Heart Association and the American Stroke Association are voluntary organizations whose mission is to reduce disability and death from cardiovascular diseases and stroke.  The Get With The Guidelines program consists of the following modules:

  1. Stroke signifies that a hospital's data shows at least 85% adherence in the 7 core Get With The Guidelines Stroke measures
    • Silver Performance Achievement Award – this criteria has been sustained for 12 consecutive months
    • Gold Performance Achievement Award – this criteria has been sustained for 24 or more consecutive months.
    • Silver Plus Performance Achievement Award –current silver award and additional 75 percent compliance with module specific quality
    • Gold Plus Performance Achievement Award –current gold award and additional 75 percent compliance with module specific quality
  2. Heart Failure signifies that a hospital's data shows at least 85% adherence in the 5 core Get With The Guidelines Heart Failure measures
    • Silver Performance Achievement Award – this criteria has been sustained for 12 consecutive months
    • Gold Performance Achievement Award – this criteria has been sustained for 24 or more consecutive months.
    • Silver Plus Performance Achievement Award –current silver award and additional 75 percent compliance with module specific quality
    • Gold Plus Performance Achievement Award –current gold award and additional 75 percent compliance with module specific quality

The Get with the Guidelines program denotes levels of performance over time. The designation is represented by the first year the designation was achieved and the performance level attained. This designation is in effect until the organization performance level changes.

Center for Medicare & Medicaid Services (CMS) Hospital Quality Initiative
Designates that a hospital has agreed to submit performance measures for publication on the Centers for Medicare and Medicaid (CMS) website. 

John M. Eisenberg Award for Patient Safety and Quality:
Recognizes major achievements of individuals and organizations in improving patient safety and quality.  Organization awards are presented in the categories of system innovation (local and national) or research.

The Magnet Award:
The highest level of recognition the American Nurses Credentialing Center (ANCC) accords to organized nursing services. The award recognizes health care organizations exhibiting excellence in nursing services to patients, the existence of an environment that supports professional nursing practice and growth and development of nursing staff.  Magnet institutions act as "magnets" by attracting and retaining outstanding nurses and creating a work environment that recognizes and rewards professional nursing.

Malcolm Baldrige National Quality Award:
Established by Congress to promote quality awareness, to recognize quality and business achievements of U.S. organizations, and to publicize the award winners' successful performance strategies.  Awards are given in manufacturing, service, small business, education, and health care.  This award is presented annually by the President of the U.S.

The Medal of Honor for Organ Donation:
U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA)  is focusing efforts on reducing the gap between potential organ donors and needy recipients.  The principle aim of this effort is to encourage hospitals to achieve and maintain organ donor conversion rates exceeding 75% or higher of eligible donors.  HRSA sponsors an Organ Donation Breakthrough Collaborative.

  • The Medal of Honor for Organ Donation:  Recognizes organizations that have raised their donation rates to 75% or higher of eligible donors for the past 12 months.

Mental Health Risk Retention Group, Inc., (MHRRG) Negley Awards for Excellence in Risk Management:
Established in 1990, by Negley Associates, Inc., underwriting managers for the Mental Health Risk Retention Group. They recognize outstanding achievements in risk management by community mental health centers and offer the opportunity to expand services otherwise not available. In addition, winners share their risk management strategies with the mental health community. There are three awards:

  • President's Award
  • Chairman's Award
  • Board of Director's Award

National Council for Community Behavioral Healthcare and Association of Behavioral Healthcare Management (NCCBH) Awards of Excellence Program:
The NCCBH is the nation's oldest and largest trade association for providers of mental health, substance abuse and developmental disability services are recognizes outstanding achievement by organizations within the field.

Nursing Homes/Long Term Care Management Magazine OPTIMA Award:
Recognizes innovative and outcome-oriented teamwork that improves the care and quality of life of the residents in long-tem care facilities.

Patient-Centered Designation Program:
The Planetree Patient-Centered Designation Program recognizes hospitals that have embraced and implemented patient-centered care in a comprehensive manner, improving both clinical and patient satisfaction outcomes. Based on the core elements of a personalized, humanized and demystified approach to healthcare, 54 specific criteria must be met in order to demonstrate that a site has implemented that dimension of patient-centered culture. The program is designed to celebrate achievement, as well as to provide a concrete and measurable framework for comprehensive implementation of patient-centered care. In this spirit, the criteria a healthcare organization must meet focus on both process and outcomes. The criteria reflect the experiences of hospitals that have been engaged in an ongoing, focused effort to cultivate a culture of patient-centered care over the period of several years.


The 54 Planetree Patient-Centered Designation Program criteria are categorized within the following areas:
  1. Structures and Functions Necessary for Implementation,
    Development, and Maintenance of Patient-Centered Concepts and Practices
  2. Human Interactions
  3. Patient Education and Access to Information
  4. Family Involvement
  5. Nutrition Program
  6. Healing Environment:  Architecture and Interior Design
  7. Arts Program
  8. Spirituality and Diversity
  9. Integrative Therapies
  10. Healthy Communities
  11. Measurement  

Compliance with the designation criteria is verified through an assessment process that includes a written self-assessment, focus groups with patients, leadership and staff, and a review of outcomes measures. The Planetree Patient-Centered Designation Program was created by Planetree, a not-for-profit organization founded by a patient, which has been working with healthcare providers for more than 30 years to personalize, humanize and demystify healthcare for patients.

Scheduled Survey Date

The date an organization is to begin its full survey.

Standard Deviation

A measure of variability that indicates the spread of a set of observations around the mean.

State/Location - How Do I Select an Area to Search?  (Advanced Search Only)


To view the areas that can be searched:

  1. Click on the down arrow.
  2. When the list appears, click on the area that you wish to search.
  3. To select an area that is not shown when the list appears, click on either the scroll up or the scroll down arrows on the scroll bar. When the desired area appears, click on it. 
  4. You can choose up to four locations per search.

What Does the State/Location List Contain? 

All 50 states and any non-United States locations, such as Virgin Islands, where organizations have been accredited. 

How Is the List Organized? 

Each list is in alphabetical order. 

What Does the <ALL LOCATIONS> Option Do? 

The <ALL> option allows you to search on all of the listed areas.

Show Organization's Main Site Only (Advanced Search Only)

This search option will show the parent organization only.  All other sites of care will not be displayed.

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Type of Care - How do I search by Type Care? (Advanced Search Only)

  1. If you want to see all types of care, no choice is needed.
  2. If you want to choose a particular type of care, click on the name of the care.

Note:  When you select a provider type the "Type of Care" box will automatically show the kinds of care for that provider.

Type of Provider  

Joint Commission accreditation program descriptions: 

  • Ambulatory Care (Outpatient Care): Ambulatory care providers, including outpatient surgery facilities, rehabilitation centers, infusion centers, group practices and others.
  • Ambulatory Care / Office-Based Surgery:  Health Care organizations or practices composed of five or more doctors performing surgical procedures.
  • Behavioral Health Care:  Behavioral health care organizations, including those that provide mental health, chemical dependency, child welfare, foster care, and mental retardation/developmental disabilities services for clients of various ages in various organized service settings.
  • Critical Access Hospital:  Hospitals with a patient census of less than 25 and that are located more than 35 miles from a hospital or another critical access hospital, or are certified by the state as being a necessary provider of health care services to residents in the area.
  • Home Care Providers:  Home care organizations, including those that provide home health services, personal care and support services, home infusion(intravenous or IV Therapy) and other pharmacy services, durable medical equipment services and hospice services.
  • Home Care/Hospice Deemed Status: Home care agencies and hospices that receive federal payment from Medicare or Medicaid programs.  The organizations must be certified as complying with the Conditions of Participation, or standards, set forth in the federal regulations.
  • Hospital:  General medical/surgical, psychiatric, long term care acute, rehabilitation and surgical specialty.
  • Nursing Care Center:  Skilled Nursing Facilities, nursing homes, and hospital based beds licensed as long term care, including subacute care and transitional care units.
  • Long Term Care Deemed Status: Facilities that receive federal payment from Medicare or Medicaid programs.  The organizations must be certified as complying with the Conditions of Participation, or standards, set forth in the federal regulations.
  • Medicare-Medicaid Certification-Based Long Term Care: Medicare/Medicaid certification based long term care accreditation is a one-day/one fee LTC survey that is based on a sub-set of LTC standards that do not duplicate the CMS Conditions of Participation. Available for Medicare/Medicaid certified skilled nursing facilities/nursing facilities.
  • Office-Based Surgery Facilities:  Small organizations or practices composed of four or fewer doctors performing surgical procedures.
  • Pathology and Clinical Laboratory:  Hospital-based main laboratories or testing facilities, free-standing laboratories, embryology laboratories, reference laboratories, blood banks and donor centers.

Top Performer on Key Quality Measures®

The Joint Commission’s  Top Performer on Key Quality Measures® recognizes accredited hospitals and critical access hospitals that attain and sustain excellence in accountability measure performance. Recognition in the program is based on an aggregation of accountability measure data reported to The Joint Commission during the previous calendar year. This recognition will occur in the fall of each year and will coincide with the publication of The Joint Commission’s “Improving America’s Hospitals” annual report. Each year, the percentage of top performing hospitals will vary. (Most Joint Commission accredited hospitals are required to report performance measure data to The Joint Commission while many critical access hospitals voluntarily report these data.)

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UHMS Clinical Hyperbaric Facility – Level 1

Level I Hyperbaric Program: a hyperbaric program that offers a full scope of service for the hyperbaric patient. They are typically hospital-based facilities that cover all recognized indications, including emergency life or limb threatening and are available for treatment of the emergent patient 24/7. (This would be comparable to a Level I trauma center.)

UHMS Clinical Hyperbaric Facility – Level 2

Level II Hyperbaric Program: a hyperbaric program that provides a reduced scope of service for the hyperbaric patient (does not treat emergency patients) in the hospital setting and is not available 24/7. Generally, these are programs that typically provide high quality care to chronic outpatients patient Monday - Friday and are not equipped or staffed for emergency indications

UHMS Clinical Hyperbaric Facility – Level 3

Level III Hyperbaric Program: a hyperbaric program that provides appropriate hyperbaric therapy in the nonaffiliated setting (non hospital).

Universal Protocol For Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery

Wrong site, wrong procedure, wrong person surgery can be prevented. This universal protocol is intended to achieve that goal. It is based on the consensus of experts from the relevant clinical specialties and professional disciplines and is endorsed by more than 40 professional medical associations and organizations.  For more information see Facts about Universal Protocol.

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Zip Code - What Are the Rules for Searching on a Zip Code? (Advanced Search Only)

  1. You must enter a five digit zip code to search.
  2. Select a distance from the "drop down menu" from 0 to 500 miles.  Your search will display all health care providers within the distance from the zip code you entered.

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