Improvements continue in surgical care accountability measures

In November 2015, The Joint Commission recognized 1,043 hospitals for outstanding performance on accountability measures as part of its Top Performer on Key Quality Measures program. These institutions comprise 31.5 percent of all Joint Commission-accredited hospitals that reported accountability measure performance data for 2014 and included general, critical access, children’s, psychiatric, surgical, and cardiac-specialty hospitals.

The Joint Commission began emphasizing accountability measures in 2010, when it categorized its process performance measures as accountability and non-accountability measures. Accountability measures meet four criteria designed to identify measures that have proven to produce the greatest positive effect on patient outcomes: research, proximity, accuracy, and adverse effects. Non-accountability measures are suitable for secondary uses, such as exploration or learning within individual health care organizations, and can offer guidance for providing appropriate patient care.

Achieving Top Performer status

To be designated as a Top Performer, a hospital had to achieve cumulative performance of 95 percent or above on all reported accountability measures and 95 percent or above on each reported accountability measure, with at least 30 denominator cases. Top Performers also had to have at least one core measure set with a composite rate of 95 percent or above and, within that measure set, have achieved a performance rate of 95 percent or above on all applicable individual accountability measures—meaning a hospital provided an evidence-based practice 95 times out of 100.

Hospitals reported on seven performance measures in the surgical care measure sets for 2014. The average number of hospitals reporting data throughout the program is 2,060.

The 2014 data for those measures were as follows:

  • 99.9 percent of hospitals reported that surgery patients had appropriate hair removal.
  • 99.8 percent of surgery patients received appropriate venous thromboembolism prophylaxis within 24 hours before an operation to 24 hours after an operation.
  • 99 percent of hospitals reported giving patients a prophylactic antibiotic within one hour before surgical incision.
  • 98.7 percent of hospitals selected a prophylactic antibiotic for surgical patients.
  • 98.4 percent of patients had a urinary catheter removed on postoperative day (POD) one or POD two with day of surgery defined as day zero.
  • 98.3 percent of hospitals reported that prophylactic antibiotics were discontinued within 24 hours after an operation’s end time.
  • 98.3 percent of surgery patients on a beta-blocker prior to hospital arrival received a beta-blocker during the perioperative period.

When the surgical care measure set was introduced in 2005, it included only three measures: prophylactic antibiotics within one hour prior to surgical incision; prophylactic antibiotic selection for surgical patients; and discontinuing prophylactic antibiotics within 24 hours after an operation’s end time. Therefore, those three measures have the most robust data for year-to-year comparison purposes. Also, each of these measures report on rates for the following seven types of surgery:

  • Coronary artery bypass grafting surgery
  • Other cardiac surgery
  • Colon surgery
  • Hip arthroplasty surgery
  • Hysterectomy surgery
  • Knee arthroplasty surgery
  • Vascular surgery

More data on these procedures can be found in The Joint Commission’s 2015 annual report, America’s Hospitals: Improving Quality and Safety, available on The Joint Commission’s website.

Focus on what counts

At a November 17, 2015, press conference to announce the annual report, Joint Commission president and chief executive officer Mark R. Chassin, MD, MPP, MPH, FACP, said the Top Performer program identifies hospitals with a record of extraordinary performance on an increasing number of important quality measures. However, he said the report rates only certain measures of quality of care in hospitals.

“In fact, the evidence is crystal clear that quality varies quite a lot within individual hospitals—from one service to another, and from one measure to another,” Dr. Chassin said. “That’s why we are very careful to specify in this report exactly which measures resulted in each Top Performer achieving their recognition. This is just one of many Joint Commission programs that address many different aspects of quality in hospitals and all the other health care organizations we work with. Achieving the Top Performer eligibility criteria is not easy, and for most hospitals, it took many years of hard work. More than ever, hospitals are focusing on what counts. This represents real progress.”

Dr. Chassin noted that improvements on individual measures since 2010 have ranged from small fractions of a percentage point to as much as 38.7 percentage points.

“It is important to note that relatively small percentage point improvements in measures, especially those for which performance is already strong, can often require as much or even more diligence than large percentage point improvements where much room for improvement exists,” Dr. Chassin said. “All improvements are important and contribute to better care for patients.”

In 2010, the composite rate for Joint Commission-accredited hospitals submitting data for surgical care accountability measures was 96.4 percent. In 2014, it was 99.1 percent—an improvement of 2.7 percentage points.

In the press conference, Dr. Chassin also announced that the Top Performer program will take a hiatus for 2016 in order to reevaluate the program to better fit the evolving national measure environment—particularly within the Centers for Medicare & Medicaid Services (CMS). CMS has made significant changes to the performance measures in the Hospital Inpatient Quality Reporting program, including retiring a number of chart-based measures (Note: The surgical care measures are chart-based, having all been retired over the past four years, with the last measure retired as of December 31, 2015).

The Joint Commission will return with a refreshed program that will better fit the evolving national measure environment while supporting Top Performers and hospitals on track to achieving this recognition.

For more information on accountability measures, visit The Joint Commission’s website.


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

Tagged as: , ,


Bulletin of the American College of Surgeons
633 N. Saint Clair St.
Chicago, IL 60611


Download the Bulletin App

Get it on Google Play