Annual report provides details on patient safety, quality improvements

The Joint Commission's Annual Report 2016Hospitals in the U.S. continue to make strides in improving patient safety and quality for common conditions, according to America’s Hospitals: Improving Quality and Safety: The Joint Commission’s Annual Report 2016.

The report, released November 7, 2016, presents information on how more than 3,300 Joint Commission-accredited hospitals performed on individual, chart-abstracted measures of patient care during 2015 in comparison to previous years.

Reporting data on these measures is a requirement of Joint Commission-accredited hospitals. A total of 33 measures were described in the report, 29 of which were accountability measures, focused on evidence-based care processes that are closely linked to positive patient outcomes. The measures are relevant for accreditation, public reporting, and pay-for-performance programs that hold providers accountable to external oversight entities and the public.

Measures in the report

The chart-abstracted measures covered in the report pertain to the following:

  • Children’s asthma management (one measure)
  • Inpatient psychiatric services (seven measures)
  • Venous thromboembolism (VTE) care (five measures)
  • Stroke care (eight measures)
  • Perinatal care (five measures)
  • Immunization (one measure)
  • Tobacco use treatment (three measures)
  • Substance use care (three measures)

Some measures, such as those comprising perinatal care, show significant gains. In 2015, the perinatal care result was 97.6 percent—up from 53.2 percent in 2011, which is an improvement of 44.4 percentage points.

Another is the VTE care result, which came in at 95.2 percent in 2015—up from 89.9 percent in 2011—an improvement of 5.3 percentage points. VTE medicine and/or treatment in an intensive care unit was 94.5 percent in 2011 and 97.4 in 2015—a difference of 2.9 percentage points.

Any improvements, no matter how large or small, are important because they all contribute to better care for patients. As a result of continued excellent performance, three of four individual VTE care accountability measures were retired effective December 31, 2015.

Meanwhile, strong reporting performance led to the retirement of all Surgical Care Improvement Project (SCIP) chart-abstracted measures in 2015. This decision was based largely on the fact that the composite scores were so high, ranging in 2014 from 94.2 percent on the low end (appropriate prophylactic antibiotics for colon surgery) to 99.9 percent on the high end (patients with appropriate hair removal).

Pioneers in Quality recognized

This year’s annual report also recognizes 39 Pioneers in Quality hospitals that are at the forefront of a new era in health care quality reporting—one in which hospitals collect information on the quality of patient care through electronic health records (EHRs) and report the data to The Joint Commission and the Centers for Medicare & Medicaid Services (CMS). To be recognized as a 2016 Pioneers in Quality organization, a hospital had to meet criteria in at least one of three of The Joint Commission’s categories of participation. These categories of participation are as follows:

  • Expert contributor: Advancing the evolution and use of electronic clinical quality measures (eCQMs) through contributions such as presenting at a Pioneers in Quality webinar or participating in eCQM development in 2016.
  • Solution contributor: Submitting an eCQM solution or implementation story to The Joint Commission’s Core Measure Solution Exchange, a quality improvement tool that promotes the sharing of performance measurement successes among accredited hospitals. To access the database and share your institution’s success stories, go to the Joint Commission website.
  • Data contributor: Voluntarily transmitting 2015 eCQM data in 2016.

In 2016, hospitals also will have available to them new eCQMs on surgical care and emergency department measures to report. These electronic (e) SCIP measures are as follows:

  • Antibiotics within one hour before the first surgical incision (eSCIP-INF-1a)
  • Urinary catheter removed (eSCIP-INF-9)
  • Median time from ED arrival to ED departure for admitted ED patients (eED-1a)
  • Admit decision time to ED departure time for admitted patients (eED-2a)

“The results featured in The Joint Commission’s 2016 Annual Report are important because they show that accredited hospitals have continued to improve the quality of the care they provide, and the data that hospitals collect help them identify opportunities for further improvement,” said Mark R. Chassin, MD, MPP, MPH, FACP, president and chief executive officer, The Joint Commission. “The results also show it’s important to note that where a patient receives care makes a difference. Some hospitals perform better than others in treating particular conditions.”*

To read the complete America’s Hospitals: Improving Quality and Safety: The Joint Commission’s Annual Report 2016 online.

The Joint Commission's Annual Report 2016


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

*The Joint Commission. Joint Commission report shows America’s hospitals continue to improve patient care. Press release. November 7, 2016. Available at: Accessed November 30, 2016.

Tagged as: , ,


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


Download the Bulletin App

Apple Store
Get it on Google Play
Amazon store