The Joint Commission
Quality Check

Frequently Asked Question about Quality Check and Quality Reports 
(Updated 5/13/2009)

 

 

General Questions about Quality Check

Q. What is Quality Check?
A. Quality Check® is The Joint Commission’s search engine to locate Joint Commission accredited health care organizations in the United States.  Visitors can search by city and state, by name or by zip code.

Q. I'm on a Macintosh computer, can I use Quality Check?
A. Quality Check is best viewed on a Windows operating system with Internet Explorer browser, version 5.0 or above.  For Macintosh users, Quality Check is best viewed with operating systems 10 and above on a Safari browser.  These versions may require more up and down scrolling to view search results.  Some older versions of Macintosh operating systems, 9.0 or lower, may experience problems, especially when viewed with Internet Explorer for Macs.

Q.  How often is Quality Check updated?  I want to see the hospitals that have been surveyed recently.
A.  Quality Check is updated on a daily basis to incorporate any updates to accreditation/certification decisions.  Generally, a new Quality Report is issued for an organization 90 to 120 days following its onsite survey/review.  Be sure to add www.qualitycheck.org to your “favorites” on your computer and return to the site frequently to get updated information.

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General Questions About Quality Reports

Q.  What is a Quality Report?
A.  There are two types of quality reports; an Accreditation Quality Report and a Certification Quality Report.  

  • Accreditation Quality Report - provides detailed information about an organization’s performance and how it compares to similar organizations; the organization’s accreditation decision and the effective dates of the accreditation award; the Last Full Survey Date and Last On-Site Survey Date, programs accredited by The Joint Commission, and programs or services accredited by other accrediting bodies; compliance with The Joint Commission's National Patient Safety Goals; special quality awards; and, for hospitals, performance on National Quality Improvement Goals.  If an organization has achieved both Joint Commission certification and accreditation, their Accreditation Quality Report will contain both certification and accreditation information.  These organizations will also have a separate Certification Quality Report.
  • Certification Quality Report - provides information on a program’s certification decision and the effective date, as well as the Last Full Review Date and Last On-Site Review Date; programs certified by The Joint Commission; certified locations of care; and compliance with The Joint Commission's National Patient Safety Goals (as applicable to disease-specific care certifications).  If an organization has achieved both Joint Commission certification and accreditation, their Accreditation Quality Report will contain both certification and accreditation information.  These organizations will also have a separate Certification Quality Report.

Note:  Quality Reports are only issued for Joint Commission-accredited/certified organizations.  Look for the Gold Seal of Approval™ on the search results screen.

Q.  How do I use the Quality Report?
A.   The Quality Report is one information source to use when selecting a health care organization. You should discuss the Quality Report with your doctor or other health care professionals before making a care decision.

Q.  Are there links to accredited organizations on the Quality Report?
A.  Yes, the Quality Check search results screen and the individual organization’s summary page have links to accredited organizations and organizations with certified programs that have provided The Joint Commission with a website address.

Q. How does the Quality Report list sites and services?
A. The Quality Report contains an inventory of all sites and services for a health care organization.  The service information has been simplified from the services submitted on the application for accreditation/certification.

Q.  Is there supporting documentation to help the general public and health care professionals understand the Quality Report?
A.  Yes.  First, a glossary of terms is available. An individual can click on terms to access the glossary. Also, additional information is available on the left navigation of the Quality Report.  Health Care Professional and General Public user guides are available online or by request.

Q.  Am I able to print the Quality Report?
A.  Yes, a printer-friendly version of the Quality Report and all additional information is available.  The printer-friendly version requires Adobe Reader to view.  We recommend downloading the latest version of Adobe Reader. 

Q. How can the public access Quality Reports?
A.  The public can access Quality Reports by going directly to www.qualitycheck.org. or from the Quality Check section of The Joint Commission website, www.jointcommission.org.

Q.  Is the Joint Commission considering the reading level appropriate for the public?
A.  Yes, the Quality Reports have been reviewed for appropriate reading levels.  "Consumer friendly" content is always a challenge, as the nature of the information can be complex, however, reading level is always considered.

Q.  How often and under what circumstances will the Quality Report change?
A.  The accreditation, certification, demographic, and National Patient Safety Goal information will be updated when there are changes. The National Quality Improvement Goal information for hospitals will be updated quarterly.

Q. What is Last Full Survey/Review Date?        
A. The Last Full Survey/Review Date represents the end date of the on-site survey/review that began the listed program's current accreditation cycle.

Q. What is Last On-Site Survey/Review Date?         
A. The Last On-Site Survey/Review Date represents the end date of the most recent on-site survey/review.

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Using the Consumer Search

Q. Why can’t I find a health care organization that I know exists?
A. The Quality Check directory includes an inventory of all Joint Commission accredited organizations. The health care organization that you are searching for may not be accredited by The joint Commission 

Q. How can I search to see if my local healthcare organization is accredited by the Joint Commission? 
A. You can search in three ways” option has been added to the search results display page.  To view only organizations accredited by The Joint Commission, use the “Filter by Accreditation Type” option and select “Joint Commission Accredited”.

Q. How can I search to see if my local healthcare organization is accredited by the Joint Commission?
A. You can search in three ways

  1. By Organization Name - to limit the search results you can also choose a state
  2. By Zip Code - to expand the search results you can choose miles from the zip code from 5 to 250 miles.
  3. By State - to limit the search results you can select a city too.

Q. How many steps does it take to complete the new search?
A.  For a zip code search or state search, there are two steps:

  1. Enter the zip code or state
  2. Select the type of health care organization you are looking for, such as hospital or nursing home or type of service such as  heart or cancer (Returned organizations are dynamically created based on the zip code or state entered)
    • Once a type of service is selected, the health care organizations displayed can be filtered by type of provider, setting of care, or patient population. 

For a name search there is one step:

  1. Enter the organization's name (Hint:  Less is more, for example if you are searching for Southwest Memorial Community Hospital, enter "Memorial")

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Special Quality Awards

Q.  What special quality awards can be listed in a Quality Report?
A. The Joint Commission Board of Commissioners approved "Special Quality Distinction Awards" that recognize performance above and beyond accreditation that will be included in the Quality Report. The currently approved distinctions are the Ernest Amory Codman Award, John M. Eisenberg Award for Patient Safety and Quality, Malcolm Baldrige National Quality Award, Franklin Award of Distinction, Magnet Hospital Status, The American Hospital Quest for Quality Prize, Cheers Award, American Health Care Association (AHCA)/National Center for Assisted Living (NCAL)Quality Award, Nursing Homes/Long Term Care Management Magazine OPTIMA Award, National Council for Community Behavioral Healthcare and Association of Behavioral Healthcare Management (NCCBH) Awards of Excellence Program, Mental Health Risk Retention Group, Inc., (MHRRG) Negley Awards for Excellence in Risk Management, The Medal of Honor for Organ Donation, Get With The Guidelines,  ACS Bariatric Surgery Center Network Accreditation Program, American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), ASMBS Bariatric Surgery Centers of Excellence®, Department of Veterans Affairs National Surgical Quality Improvement Program (VA NSQIP),  and the Patient-Centered Designation Program.

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National Patient Safety Goals

Q.  What are National Patient Safety Goals and why are they important?
A.  National Patient Safety Goals and their requirements are a series of specific actions that accredited organizations and disease-specific certification programs are expected to take in order to prevent medical errors such as miscommunication among caregivers, unsafe use of infusion pumps, and medication mix-ups.  A panel of national safety experts has determined that taking these simple, proven steps will reduce devastating medical errors. Quality Reports will not display National Patient Safety Goal results for assisted living, critical access hospital, office-based surgery, or preferred provider organizations surveyed in 2003. 

Q.  How are National Patient Safety Goals scored?
A.  National Patient Safety Goals are scored as a "check" to show the implementation of the goal or an acceptable alternative; a "minus" to show lack of compliance with the goal; or an N/A to show the goal does not apply to this organization.

Q. What if an organization has a "minus" on a National Patient Safety Goal?
A.  A minus means the organization has not implemented the safety goal requirement or an acceptable alternative. The standard associated with the goal will be listed as out of compliance on the Summary of Quality page of the Quality Report.

Q. When will a National Patient Safety Goal be a "minus?"
A. National Patient Safety Goals will be marked with a "minus" when the organization's accreditation decision is other than "Accredited" or the standard associated with the goal requirement is out of compliance.

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National Quality Improvement Goals

Q.  What are National Quality Improvement Goals?
A.  These goals are optimal care for treating patients with these six conditions – childrens’ asthma care, heart attack, heart failure, pneumonia, perinatal and surgical care improvement project. These conditions are the most common reasons that patients go to the hospital and they affect hundreds of thousands of patients each year. Patients who are treated according to these guidelines are more likely to improve or and have good outcomes of care.

Q. Why are National Quality Improvement Goals important?
A. Health care providers and practitioners recognize these as "desirable goals" for treating patients with the identified conditions.

For example, these are a few of the Quality Improvement Goals a hospital should follow for patients who suffer a heart attack. 

  • Receive aspirin within 24 hours before or after hospital arrival. 
  • Assure that the patient is discharged from the hospital on aspirin. 
  • Give the patient advice and education to stop smoking. 
  • Give the patient a prescription for a beta blocker. 
  • Other conditions might prevent certain treatment for a patient. The patient should discuss these matters with his/her doctor.

Q.  How are National Quality Improvement Goals results calculated?
A. National Quality Improvement Goals are calculated for requirements that relate to treatment of a specific type of condition, such as heart attack. The hospital's results are compared to other hospitals that report on the same condition and requirements. The results are analyzed and displayed using symbols to indicate the level of performance.

Results are reported by symbols and comparative scores. Results for the past four quarters for the measure are totaled and the average result is calculated. The calculated result for the hospital is compared to the results of all other hospitals that have reported on this condition and related requirements. An organization's results are reported in comparison to all Joint Commission-accredited hospitals in the nation and to all Joint Commission-accredited hospitals in the state.

Q.  How often are National Quality Improvement Goals calculated?
A. National Quality Improvement Goals are calculated quarterly. The most recent 12 months of data available is used for the calculations.

Q. When will the National Quality Improvement Goals be updated?
A. The National Quality Improvement Goal results will be updated quarterly. When the results are updated, the oldest quarter of data will be "rolled off," the most recent quarter of data available will be added, and the results recalculated.

Q.  Hospital X got a minus on a requirement – what does that mean?
A.  A minus means that for the requirement, this organization’s performance is below the target range/value.  The hospital has an opportunity to improve in this area.

Q.  Hospital X got a check mark on a requirement – what does that mean?
A.  A check mark means that for the requirement, this organization’s performance is similar to the target range/value.

Q.  Hospital X got a plus on a requirement – what does that mean?
A.  A plus means that for the requirement, this organization’s performance is above the target range/value

Q.  Hospital X got a star on a requirement – what does that mean?
A.  A star means that for the requirement, the hospital's achieved the best possible result for that requirement.

Q.   Is Hospital Y better than Hospital X because it got a plus on a requirement and Hospital X did not?
A.  Not necessarily. The requirements are reported on one specific aspect of care. The care patients receive at a hospital depends on many factors-- doctors, nurses, type of treatment, etc. The Quality Report is one tool to assist you in selecting health care. Patients should discuss the Quality Report and its contents with their doctor or other health care provider to help them make an informed choice.

Q.  Will there be a date range for the National Quality Improvement Goals?
A.  Yes, the reporting period for the National Quality Improvement Goals will be displayed in the Quality Report.  New National Quality Improvement Goals data will be posted quarterly.

Q.  Will the scoring symbols used on the Quality Report, e.g. check marks, minuses, and pluses be defined?
A.  Yes, all scoring will include a "key" to define the scoring symbols. In addition, all scoring will be defined by "mousing over" symbols when viewing on the web.

Q. Why would the reports of the National Quality Improvement Goals and the National Voluntary Hospital Reporting Initiative be different on The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) websites?
A. Although the Joint Commission and CMS are working together to collect the same data, reports may be different because:

  1. The data collected for the Quality Report are collected from Joint Commission-accredited hospitals.  CMS' data are from hospitals participating in the Centers for Medicare & Medicaid Services (CMS) Hospital Quality Initiative, which includes Joint Commission-accredited hospitals as well as hospitals not accredited by the Joint Commission.
  2. The reporting time period may be different for The Joint Commission presentation on the Quality Report compared to the presentation on the CMS Hospital Compare web site.  (Example The Joint Commission waits 2 quarters before presenting data for a new measure while CMS can present after only one quarter of data collection).
  3. The Joint Commission and CMS collect different measures.
  4. The Joint Commission reports a rolling four quarters of measure data.  CMS does not.

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Quarterly Data Points for the National Quality Improvement Goals

As of January 2007, consumers are able to access additional detail about Joint Commission accredited health care organizations’ National Quality Improvement Goal data.  Measure compliance rates for each of the last four individual quarters are available. This is in addition to compliance rates for the combined last four quarters, which are currently provided on Quality Check. Rates provided are for the hospital, state, and nation.

Q. How often will quarterly data points be updated?
 
The four quarter aggregate data and the individual quarterly data points will be available on the same file and updated at normal reporting periods throughout the year on Quality Check. 

Q. How do I access an organization’s quarterly data points?
The Quality Check search engine gives you access to quarterly data points.  The quarterly data points are an additional “drill down” feature for each measure.  The quarterly data display is accessed by clicking on the “See Quarterly Results” link from the measure detail page (see image below)

 

Quarterly Data Points FAQs
 
Q. How are quarterly data points displayed?
A. For process measures, the hospital’s number of eligible patients, the hospital’s rate and the nationwide average are displayed.  For outcome measures, the hospital’s number of eligible patients, the hospital’s actual rate and the hospital’s expected rate are displayed.

Process Measure Display:

Quarterly Data Points FAQs
 
Outcome Measure Display:

Quarterly Data Points FAQs
 
Q. Why do some measures have “No Quarterly Results are available?”

Quarterly Data Points FAQs


A. The message “No Quarterly Results are available” will be displayed for any of the situations listed below: 

  • If the measure information is not displayed at the aggregate level, then it will be suppressed at the individual quarter level.  
  • If the organization reported 0 eligible patients for the four quarters of the reporting period. 
  • If the measure is a new measure that has not been in effect for the first three of the four quarters of the reporting period.  The fourth quarter will be a place holder for the new measure and no rates will be displayed.  Therefore there will not be any information to display.

Q. What does the “----“symbol represent?
A. Four dashes (----) indicate a Null value or data not displayed.   A corresponding footnote will indicate why the data is not displayed.  If there is no corresponding footnote, then the data value is assumed to be null.

Q. What is the Privacy Disclosure Threshold rule indicated in footnote #4?
A. Footnote #4 has been revised.  The new version of Footnote #4 reads:
“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.

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Comparing Organizations

Q. Can I compare one organization's Quality Report against another organization's report?
A. Yes, however, you can only compare hospitals.  Up to six Joint Commission-accredited hospitals can be compared at one time.

Q.  My local hospital has four sites of care.  Can I compare those four sites?
A.  No.  The Joint Commission issues Quality Reports for the parent organization only.  Comparisons cannot be made for sites of care from the same parent organization.

Q.  After checking the "compare" box for several hospitals, I found that there is no way to make the comparison happen.  How do I see the comparison?
A.  After you check the "compare box," for up to six organizations, just click on the blue "Compare Hospitals" button at the top or bottom of the page.

Q. What will the comparison show me?
A. The comparison will show the National Quality Improvement Goals for each hospital selected.

Q. How do I select hospitals to compare?
A.  In Quality Check you must follow these three steps:

  1. Perform a name, zip code or state search 
  2. On the search results screen, click on the check box next to the hospital name (Remember only hospitals can be compared so other organizations will not have check box next to their name) 
  3. Click on the blue "Compare Hospitals" button at the top or bottom of the page. 

The comparison results for the National Quality Improvement Goals will now be displayed.  You can then click on a particular National Quality Improvement Goal, such as Heart Attack Care, for further comparison.

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