Accreditation Decisions
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Accredited
is awarded to a health care organization that is in compliance with all standards at the time of the on-site survey or has successfully addressed requirements for improvement in an Evidence of Standards Compliance within 60 days following the posting of the Accreditation Summary Findings Report and does not meet any other rules for other accreditation decisions.
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Accreditation with Follow-up Survey
results when a health care organization is in compliance with all standards, as determined by an acceptable ESC submission. A follow-up survey is required within six months to assess sustained compliance.
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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; submission of falsified documents or misrepresented information, lack of a required license or similar issue at the time of survey, failure to resolve the requirements of an Accreditation with Follow-up Survey status; patients having been placed at risk for serious adverse outcomes due to significant or pervasive patterns/trends/repeat findings, or significant noncompliance with Joint Commission standards. This decision is subject to review and appeal before the determination to deny accreditation.
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Denial of Accreditation
results when a health care organization has been denied accreditation. All review and appeal opportunities have been exhausted.
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Limited Temporary Accreditation
results when the health care organization demonstrates compliance with selected standards in the surveys conducted under the Early Survey Policy.
Accreditation Programs
Joint Commission accreditation program descriptions:
Ambulatory care providers, including outpatient surgery facilities, rehabilitation centers, infusion centers, group practices and others.
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.
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 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.
General medical/surgical, psychiatric, long term care acute, rehabilitation and surgical specialty, children’s
Skilled Nursing Facilities, nursing homes, and hospital based beds licensed as long term care, including subacute care and transitional care units.
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Office-Based Surgery Facilities
Small organizations or practices composed of four or fewer doctors performing surgical procedures.
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Pathology and Clinical Laboratory
Hospital-based main laboratories or testing facilities, free-standing laboratories, embryology laboratories, reference laboratories, blood banks and donor centers.
an outpatient facility that provides primary care and routine laboratory services to rural and often underserved communities. To qualify as a federally certified rural health clinic, the clinic must be in a non-urbanized area categorized as a federally designated health professional shortage area. A rural health clinic may be classified as an independent or provider-based clinic. Independent (freestanding) rural health clinics are typically physician-owned facilities. Healthcare providers operate provider-based rural health clinics as part of a hospital, home health agency, or other healthcare facility.
Advanced Certification Programs
- Advanced Certification in Perinatal Care
promotes evidence-based practices and certification standards to help organizations improve prenatal, intrapartum and postpartum patient care services. In order to receive advanced certification from TJC, organizations must meet eligibility requirements outlined in the Comprehensive Certification Manual for Disease Specific Care and meet all ACPC standards.
Certification Decisions
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.
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.
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.
Decision Effective Date
The date of the accreditation or certification decision awarded to an organization.
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.
Verification
Verification is awarded after a review to determine that a program has met all the requirements relevant for a particular level of care. These programs either receive no Requirements for Improvement (RFIs) during the verification review, or have addressed any RFIs through an acceptable Evidence of Standards Compliance (ESC) submission for the verification findings.
Maternal Levels of Care Verification
A verification in which The Joint Commission has determined that an eligible program complies with applicable Joint Commission Maternal Levels of Care Verification requirements, based on The American College of Obstetricians and Gynecologists (ACOG) Obstetric Care Consensus: Levels of Maternal Care.
- Level I: Care for low to moderate-risk pregnancies, demonstrating the ability to detect, stabilize, and initiate management of unanticipated maternal-fetal or neonatal problems that occur during the antepartum, intrapartum, or postpartum period until the patient can be transferred to a facility at which the specialty maternal care is available
- Level II: Level I, plus moderate- to high-risk antepartum, intrapartum, and postpartum conditions
- Level III: Levels I and II, plus care for more complex maternal medical conditions, obstetric complications, and fetal conditions
- Level IV: Levels I, II, III, plus on-site medical and surgical care of the most complex maternal conditions and critically ill pregnant women and fetuses throughout antepartum, intrapartum, and postpartum care
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(Opens in a new window).
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 Information
Heart Attack Care
This category of evidence based measures assesses the overall quality of care provided to Heart Attack (AMI) patients.
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Fibrinolytic therapy received within 30 minutes of hospital arrival.
Heart attack patients who receive a medicine that breaks up blood clots (fibrinolytic therapy) within 30 minutes of hospital arrival. This measure reports how quickly heart attack patients were given a medication that breaks up blood clots (fibrinolytic 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 fibrinolytic 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.
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.
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Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
This measure reports the number of pediatric asthma patients and/or their caregivers who were given a written Home Management Plan of Care document (HMPC). The HMPC addresses all of the following: 1.) Arrangements for follow-up care; 2.) How to avoid those things that cause an asthma attack; 3.) What to do if asthma symptoms worsen after discharge; 4.) How and when to use controller medications; 5.) How and when to use reliever medications.
Stroke Care
This category of evidence based measures assesses the overall quality of care provided to Stroke (STK) patients.
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Anticoagulation Therapy for Atrial Fibrillation/Flutter
Ischemic stroke patients with atrial fibrillation/flutter who receive a prescription for an anticoagulant medication when being discharged from the hospital. This measure reports how often an anticoagulant medication was prescribed to ischemic stroke patients with atrial fibrillation/flutter when they are leaving a hospital. Atrial fibrillation is a heart rhythm disturbance that can allow blood clots to form within the upper chambers of the heart. If these blood clots break off and get into the bloodstream, a stroke can result. Anticoagulant medications or “blood thinners” help to prevent blood clots from forming.
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Antithrombotic Therapy By End of Hospital Day 2
Ischemic stroke patients receiving an antithrombotic medication by the end of hospital day 2. This measure reports what percent of ischemic stroke patients receive an antithrombotic medication, such as aspirin, the day of or day after hospital arrival. Antithrombotic medications are beneficial because they reduce the tendency of blood to clot in blood vessels of the brain and improve survival rates.
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Assessed for Rehabilitation
Stroke patients who have had their need for rehabilitation services assessed by a member of the rehabilitation team during their hospitalization. This measure reports what percent of stroke patients have a rehabilitation assessment completed or receive rehabilitation services during their hospitalization. Rehabilitation is a treatment(s) designed to facilitate the process of recovery from stroke or other injury, illness, or disease to as normal a condition as possible.
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Discharged on Antithrombotic Therapy
Ischemic stroke patients who receive a prescription for an antithrombotic medication when discharged from the hospital. This measure reports how often an antithrombotic medication, such as aspirin, was prescribed to ischemic stroke patients when they are leaving a hospital. Antithrombotic medications are beneficial because they reduce the tendency of blood to clot in blood vessels of the brain and improve survival rates.
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Discharged on Statin Medication
Ischemic stroke patients who receive a prescription for a statin medication when discharged from the hospital. This measure reports how often a statin medication was prescribed to ischemic stroke patients when they are leaving a hospital. Statin medications reduce the level of cholesterol circulating in the blood.|
Stroke patients who receive specific educational material about their condition. This measure reports what percent of stroke patients are given written instructions or educational material about their condition and care when they leave the hospital. Patient education about medicines, follow-up care after discharge, risk factors for stroke, warning signs to watch for, and activation of the emergency medical system if these signs occur is important in order to prevent another stroke.
Acute ischemic stroke patients who receive a medicine that breaks up blood clots (thrombolytic therapy) within 180 minutes of stroke symptom onset. This measure reports how quickly ischemic stroke patients were given a medication that breaks up blood clots (thrombolytic therapy). Breaking up blood clots increases blood flow to the brain. If blood flow is returned to the brain quickly during a stroke, the risk of brain damage and loss of physical function is decreased. The medicine that breaks up clots in the arteries and allows the return of normal blood flow is called thrombolytic therapy or “t-PA”. It is important that this medicine be given quickly after an ischemic stroke is diagnosed.
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Venous Thromboembolism (VTE) Prophylaxis
Stroke patients who receive treatment for the prevention of blood clots on the day of or day after hospital admission. Note: Treatment may be medication or mechanical devices for exercising the legs. This measure reports what percent of stroke patients receive treatment for the prevention of blood clots. Stroke patients are at increased risk of developing blood clots. The incidence of blood clots is lowest when patients are treated to prevent them.
Perinatal Care
This category of evidenced based measures assesses the care of mothers and newborns.
This measure reports the overall number of mothers who were at risk of preterm delivery at 24-32 weeks gestation receiving antenatal steroids prior to delivering preterm newborns. Antenatal steroids are steroids given before birth.
This measure reports the number of first-time moms with a full-term, single baby in a head-down position who delivered the baby by cesarean section. The measure focuses on mothers having their first birth who are at the highest risk of a first cesarean birth when compared to mothers who have experienced a previous vaginal birth. Mothers with multiple babies, breech presentations, and premature births are not included in the measure. The measure is designed to be an accurate way for leaders to identify whether a hospital’s rate of cesarean births for women included in this select population is consistent with the rate of cesareans within this same population at another hospital. Hospitals whose Cesarean Birth measure rates are higher than rates at other hospitals are encouraged to explore and evaluate differences in the medical and nursing management of women in labor.
This measure reports the overall number of mothers who had elective vaginal deliveries or elective cesarean sections at equal to and greater than 37 weeks gestation to less than 39 weeks gestation. An elective delivery is the delivery of a newborn(s) when the mother was not in active labor or presented with spontaneous ruptured membranes prior to medical induction and/or cesarean section.
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Exclusive Breast Milk Feeding
This measure reports the overall number of newborns who are exclusively breast milk fed during the newborns entire hospitalization. Exclusive breast milk feeding is when a newborn receives only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines.
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Exclusive Breast Milk Feeding Considering Mothers Choice
This measure reports the overall number of newborns who are exclusively breast milk fed during the newborns entire hospitalization not including those newborns whose mothers chose to not exclusively feed breast milk at the time of birth of the newborn.
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PC-06 Unexpected Complications in Term Newborns
This measure looks at the number of full-term single babies with a normal birth weight and with no preexisting conditions, these are babies that are expected to do well and routinely go home with their mother. Babies who have congenital or fetal conditions and are exposed to maternal drug use are excluded from this measure. The measure looks at complications that would be unexpected in this population. There are three rates reported: overall rate, severe rate, and moderate rate.
PC-06.0: Overall rate The overall rate equals the number of patients with severe complications plus the number of patients with moderate complications per 1000 livebirths.
PC-06.1: Severe rate The severe rate equals the number of patients with severe complications per 1000 livebirths.
PC-06.2: Moderate rate The moderate rate equals the number of patients with moderate complications per 1000 livebirths.
Emergency Department
This category of evidence based measures assesses the time patients remain in the hospital Emergency Department prior to inpatient admission.
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Admit Decision Time to ED Departure Time for Admitted Patients
The amount of time (in minutes) it takes from the time the physician decides to admit a patient into the hospital from the Emergency Department until the patient actually leaves the ED to go to the inpatient unit.
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Median Time from ED Arrival to ED Departure for Admitted ED Patients
The amount of time (in minutes) from the time the patient arrives in the Emergency Department until the patient is admitted as an inpatient into the hospital.
Venous Thromboembolism (VTE)
This category of evidence-based measures assesses the overall quality of care related to prevention and treatment of blood clots.
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Intensive Care Unit (ICU) VTE Prophylaxis
Medical and surgical patients who were admitted or transferred to the ICU who received treatment to prevent VTE or a reason why they did not need preventive care was documented. This measure reports the percent of patients who received treatment to prevent blood clots or had documentation regarding preventive care at ICU admission or transfer.
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VTE Discharge Instructions
Patients with blood clots who were discharged to home, home with home health, home hospice or discharged/transferred to court/law enforcement on a blood thinning medication with written information. This measure reports the percent of patients who went home on warfarin who received instructions about compliance issues, dietary advice, follow-up monitoring and information about the potential for adverse drug reactions/interactions.
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VTE Patients with Anticoagulation Overlap Therapy
Patients with blood clots who received two medications for treatment. This measure reports the percent of patients who received an overlap of medication for a specific timeframe, or who went home on both medications.
Medical and surgical patients who were admitted to the hospital who received treatment to prevent blood clots or a reason why they did not need preventive care was documented. This measure reports the percent of patients who received treatment to prevent blood clots or had documentation regarding preventive care at hospital admission.
Immunization
This evidence-based prevention measure set assesses immunization activity for pneumonia and influenza.
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.
Tobacco Treatment
This category of evidence based measures assesses the overall quality of care provided for tobacco use
The number of patients who were asked about tobacco use within the first three days of admission to the hospital.
The number of patients who use tobacco who actually received counseling or medications to help them stop using tobacco.
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Tobacco Use Treatment at Discharge
The number of patients who use tobacco who accepted counseling and/or medications to help them stop using tobacco after they leave the hospital.
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Tobacco Use Treatment Provided or Offered
The number of patients who use tobacco who were offered or received counseling or medications to help them stop using tobacco. This measure also includes patients who were offered the counseling and/or medications but refused them.
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Tobacco Use Treatment Provided or Offered at Discharge
The number of patients who use tobacco who were offered or accepted counseling or medications to help them stop using tobacco after they leave the hospital. This measure also includes patients who were offered the counseling and/or medications but refused them.
Substance Use
This category of evidence based measures assesses the overall quality of care provided for Substance Abuse
The number of patients who were asked about unhealthy use of alcohol within the first three days of admission to the hospital.
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Alcohol Use Brief Intervention
The number of patients who were identified as using alcohol in an unhealthy way who actually had a conversation with a healthcare professional about how drinking can harm their health and ways to stop unhealthy drinking.
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Alcohol Use Brief Intervention Provided or Offered
The number of patients who were identified as using alcohol in an unhealthy way who were offered or had a conversation with a healthcare professional about how drinking can harm their health and ways to stop unhealthy drinking. This measure also includes patients who were offered this conversation but refused the conversation.
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Alcohol and Other Drug Use Disorder Treatment at Discharge
The number of patients who were identified as having a serious problem with drinking alcohol or using drugs who either accepted a prescription to help them stop drinking or using drugs or accepted treatment for their serious problem with drinking alcohol or using drugs after they leave the hospital.
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Alcohol and Other Drug Use Treatment Provided or Offered at Discharge
The number of patients who were identified as having a serious problem with drinking alcohol or using drugs who were either offered or accepted a prescription to help them stop drinking or using drugs or were offered or accepted treatment for their serious problem with drinking alcohol or using drugs after they leave the hospital. This measure also includes patients who refused both a prescription to help them stop drinking or using drugs and treatment for their serious problem with drinking alcohol or using drugs.
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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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
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.
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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.
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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.
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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.
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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.
Assessment of violence risk, substance use disorder, trauma and patient strengths completed - Children (1-12 years)
This measure reports the number of children age (1-12 years) screened for violence risk to self and others, substance and alcohol use, psychological trauma history and patient strengths. Screening for violence risk to self-determines if patients are likely to harm themselves. Screening for violence risk to others determines if patients are likely to harm others. Screening for substance and alcohol use determines if patients need help for their use. Screening for psychological trauma history determines if patients have experienced terrible events in their lives which have left them fearful or anxious and unable to handle their feelings. Screening for patient strengths identifies positive things such as family support, a steady job, housing, etc. which are used to help the patient recover.
Assessment of violence risk, substance use disorder, trauma and patient strengths completed - Adolescent (13-17 years)
This measure reports the number of adolescent age (13-17 years) screened for violence risk to self and others, substance and alcohol use, psychological trauma history and patient strengths. Screening for violence risk to self-determines if patients are likely to harm themselves. Screening for violence risk to others determines if patients are likely to harm others. Screening for substance and alcohol use determines if patients need help for their use. Screening for psychological trauma history determines if patients have experienced terrible events in their lives which have left them fearful or anxious and unable to handle their feelings. Screening for patient strengths identifies positive things such as family support, a steady job, housing, etc. which are used to help the patient recover.
Assessment of violence risk, substance use disorder, trauma and patient strengths completed - Adult (18-64 years)
This measure reports the number of adults age (18-64 years) screened for violence risk to self and others, substance and alcohol use, psychological trauma history and patient strengths. Screening for violence risk to self-determines if patients are likely to harm themselves. Screening for violence risk to others determines if patients are likely to harm others. Screening for substance and alcohol use determines if patients need help for their use. Screening for psychological trauma history determines if patients have experienced terrible events in their lives which have left them fearful or anxious and unable to handle their feelings. Screening for patient strengths identifies positive things such as family support, a steady job, housing, etc. which are used to help the patient recover.
Assessment of violence risk, substance use disorder, trauma and patient strengths completed - Older Adult (>= 65 years)
This measure reports the number of older adult (>= 65 years) screened for violence risk to self and others, substance and alcohol use, psychological trauma history and patient strengths. Screening for violence risk to self-determines if patients are likely to harm themselves. Screening for violence risk to others determines if patients are likely to harm others. Screening for substance and alcohol use determines if patients need help for their use. Screening for psychological trauma history determines if patients have experienced terrible events in their lives which have left them fearful or anxious and unable to handle their feelings. Screening for patient strengths identifies positive things such as family support, a steady job, housing, etc. which are used to help the patient recover.
Post Discharge Continuing Care Plan Created Children Age 1 – 12
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 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 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 measure reports the number of patients age 65 and older 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 Children Age 1 – 12
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 Adolescents Age 13 – 17
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 Adults Age 18 – 64
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 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.
Descriptions of 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.
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.
Quality Check Measure Rating Methodology
Detailed information on applied methodology for rating the hospitals on their measures performance reported on Quality Check website.
Prior to 2022 data
The following methodology was used to assign a rating to a hospital for a proportion measure:
- Collect data and calculate the hospital’s measure rate.
- Calculate a confidence interval (CI) for this measure rate based on the denominator size for the measure and the inter-hospital variability for the measure (calculated using all reporting hospitals). This confidence interval for the measure will have an upper limit (UL) and a lower limit (LL).
- Starting with the national average for the measure, determine the upper target range (UTR) and the lower target range (LTR) using the following rules:
For measures where a high rate is desirable:
For example, if the national average is 80%, then the LTR is 80% and the UTR is (80 + 100)/2, or 90%.
- The confidence interval (CI) is then compared to the target range. If the CI is greater than the UTR, then the hospital receives a plus rating. If the CI is less than the LTR then the hospital would receive a minus rating. If the CI overlaps with the target range, then the hospital would receive a check rating.
For measures where a low rate is desirable:
- If the national average is less than 5%, then the LTR and UTR will be set to 5%.
- If the national average is less than or equal to 10%, but greater than or equal to 5%, then the LTR will be set to 5% and the UTR will be set to 10%.
- If the national average is greater than 10% then the LTR will be set to the half of the national average and the UTR will be set to the national average.
For example, if the national average is 20%, then the LTR is 10% and the UTR is 20%.
Ratio and CV measures
Use the national average as both the LTR and the UTR.
Starting with 2022 data
Initially, the target range methodology was used to set aspiration ranges for the measures, when measure rates tended to be suboptimal. However, this proved to be confusing to customers, therefore following new methodology will be applied starting with 2022 data reporting:
For all measures the national average is used as the target value for comparison. The new rule will be to compare the hospital’s confidence interval to the national average, so that instead of a target range there will just be one comparison value for each measure.
For measures where a high rate is desirable:
- If the CI is greater than the national average the hospital will get a plus rating.
- If the CI is less than the national average then the hospital will get a minus rating.
- If the CI contains the national average the hospital would get a check mark.
For measures where a low rate is desirable:
- If the CI is greater than the national average the hospital will get a minus rating.
- If the CI is less than the national average then the hospital will get a plus rating.
- If the confidence interval contains the national average the hospital would get a check rating.
Recognition
The acknowledgement of achievement
Leading Laboratories
A designation that recognizes laboratories who demonstrate an exemplary focus on impacting quality patient outcomes. This designation Provides.
- Public recognition of a laboratory's meaningful achievements in improving patient outcomes
- Evidence of a laboratory's commitment to the necessary ongoing professional development of its team
- Proof of laboratory leadership's commitment to their team and to patients
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.
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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.
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.
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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.
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.
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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.
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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.
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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.
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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
Special quality awards recognize 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.
1. Data Collection
2. Data Monitoring and Validation
3. Report Generation
4. Data Analysis
5. Focus on Systems
6. Feedback
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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:
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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.
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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.
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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.
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ASMBS Bariatric Surgery Centers of Excellence®
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/(Opens in a new window).
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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.
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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:
- Mark of Distinction to educate your community and stakeholders and eliminate confusion with other kinds of providers
- A Tool for Negotiation to provide a national benchmark for discussing higher fee schedules
- An Edge in Marketing to clearly and effectively describe your level of services
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
o Silver Performance Achievement Award – this criteria has been sustained for 12 consecutive months
o Gold Performance Achievement Award – this criteria has been sustained for 24 or more consecutive months.
o Silver Plus Performance Achievement Award –current silver award and additional 75 percent compliance with module specific quality
o 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
o Silver Performance Achievement Award – this criteria has been sustained for 12 consecutive months
o Gold Performance Achievement Award – this criteria has been sustained for 24 or more consecutive months.
o Silver Plus Performance Achievement Award –current silver award and additional 75 percent compliance with module specific quality
o Gold Plus Performance Achievement Award –current gold award and additional 75 percent compliance with module specific quality
3. Resuscitation signifies that a hospital's data shows at least 85% adherence in the 5 core Get With The Guidelines Heart Failure measures
o Silver Performance Achievement Award – this criteria has been sustained for 12 consecutive months
o Gold Performance Achievement Award – this criteria has been sustained for 24 or more consecutive months
o Silver Plus Performance Achievement Award – current silver award and additional 75 percent compliance with module specific quality
o 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.
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.
- 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-term 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.
UHMS Clinical Hyperbaric Facility –
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.)
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
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(Opens in a new window).