Hospitals continue to improve on surgical care accountability measures

The Joint Commission recognized 1,224 hospitals for outstanding accountability measure performance in November 2014 as part of its Top Performer on Key Quality Measures program. The hospitals represented 36.9 percent of all Joint Commission-accredited hospitals that reported accountability measure data for 2013 and included general, children’s, psychiatric, surgical and cardiac specialty, and critical access hospitals.*

To become a Top Performer, hospitals must have achieved the following:

  • A cumulative performance of 95 percent or above across all reported accountability measures
  • A performance of 95 percent or above on each reported accountability measure that had at least 30 denominator cases
  • Had at least one core measure set that had a composite rate of 95 percent or above, and within that measure set, all applicable individual accountability measures had a performance rate of 95 percent or above

Surgical care measure set

Since 2005, The Joint Commission has collected accountability measure data for surgical care. The surgical care measure set includes individual accountability measures for seven types of operations—coronary artery bypass graft (CABG), cardiac (other than CABG), colon, hip joint replacement surgery, hysterectomy surgery, knee joint replacement surgery, and vascular surgery. The three specific accountability measures are as follows:

  • Surgical patients receive a prophylactic antibiotic within one hour prior to surgical incision
  • Surgical patients receive appropriate prophylactic antibiotic selection
  • Prophylactic antibiotics are discontinued within 24 hours of the operation’s end time

Additional accountability measures within the surgical care measure set not specific to one of the seven surgical procedures identified earlier include the following:

  • Surgical patients on beta-blocker therapy prior to arrival receive a beta-blocker during the perioperative period
  • Cardiac surgery patients have controlled postoperative blood glucose
  • Surgical patients receive appropriate hair removal
  • Surgical patients receive venous thromboembolism prophylaxis within a time period of 24 hours before to 24 hours after an operation
  • Urinary catheter is removed on postoperative day one or postoperative day two with day of surgery being day zero

Since 2005, the average number of hospitals reporting accountability measure data for the surgical care measure set was 1,979, ranging from 258 to 2,766 hospitals. In 2009, the national average for Joint Commission-accredited hospitals submitting data for surgical care accountability measures was 95.8 percent. Today, that figure has increased to 98.7 percent.*

With more hospitals submitting data, the health care community is able to better gauge progress in quality improvement. As the performance of hospitals using surgical care accountability measures continues to improve, demonstrating the nationwide implementation of evidence-based quality improvement processes for surgery, more patients will receive the correct surgical care treatment, in the correct way, at the correct time.

There is still a long way to go in the development and tracking of accountability measures and other quality metrics. The Joint Commission encourages surgeons and hospitals to continue to strive for excellence in patient care and to share their solutions and challenges to help shorten the path to further quality improvement.

Joint Commission-accredited hospitals have access to the Core Measure Solution Exchange, a database of success stories from accredited hospitals that have attained excellent performance on core measures, including accountability measures. The database is available online and includes several surgical care solutions.

Visit The Joint Commission website for more information on the Top Performer program.

*The Joint Commission. 2014 Annual Report: America’s Hospitals: Improving Quality and Safety. Oakbrook Terrace, IL: The Joint Commission; 2014.

The Joint Commission. Top Performer 2014 eligibility criteria (for 2014 recognition). January 2014. Available at: Accessed November 25, 2014.

The Joint Commission. List of 2013 accountability measures. October 30, 2013. Available at: Accessed November 25, 2014.

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