Joint Commission names Top Performers on Quality Measures

By Debra Wood, RN, contributor

September 28, 2012 - A Joint Commission annual report has named 620 hospitals Top Performers, leading the use of evidence-based care processes closely linked to positive patient outcomes.

Joint Commission names Top Performers on Quality Measures
Chantal Leconte, FACHE, said earning the recognition instilled a sense of pride and a determination to make the list again next year.

“This award has instilled in our team a sense of pride and accomplishment, and gave us a strong boost in our confidence level and our determination to do well,” said Chantal Leconte, FACHE, chief executive officer at Memorial Hospital Pembroke in Pembroke Pines, Fla., which was one of only 244 facilities that received the honor both years the accrediting body has recognized Top Performers. “The team is definitely committed to going for a third time.”

Leconte credits a culture of striving to be the best and embracing evidence-based medicine, while using a systematic approach to continuous improvement, transparency and team collaboration with helping her hospital and two other Memorial facilities--Memorial Hospital West and Memorial Hospital Miramar--make the list. 

Joint Commission names Top Performers on Quality Measures
Martha Gerganoff, MSN, RN, said being recognized as a top performer by an organization such as The Joint Commission validates the work that is done daily.

“Being recognized as a top performer by an organization such as The Joint Commission validates the work that is done daily at Carondelet St. Mary’s Hospital,” said Martha Gerganoff, MSN, RN, chief operating officer/chief nursing officer at Carondelet St. Mary’s in Tucson, Ariz. “We are extremely proud to receive this recognition and attribute the accomplishment to the teamwork that drives the care provided to our patients.”

Amy Beiter, MD, FACP, chief medical officer at Carondelet Saint Mary’s, added that the hospital adheres to evidence-based best practices, uses checklists and reviews near misses for quality process measures. She also credited how well its physicians and nurses work together and hold each other accountable.

“We have an incredible culture of collaboration at this hospital,” Beiter said. “It has been a collaborative team approach to achieve what we are seeing today in outcomes.”

Joint Commission names Top Performers on Quality Measures
Amy Beiter, MD, FACP, said physicians, nurses, quality nurses and case managers all work very well together and hold each other accountable for outcomes.

John A. Brennan, MD, MPH, president and CEO of Newark Beth Israel Medical Center in New Jersey, which was named a Top Performer for the last two years, agreed about the importance of culture in sustaining high-quality care delivery.

“Our nurses and physicians are really focused on these quality indicators and outcomes,” Brennan said. “We have a management team that is focused on quality and safety, and that has helped us move to the sustainability of doing well.”

Newark Beth Israel uses software to help track measures and how the hospital is doing and where improvements are needed. The hospital celebrates its accomplishments, has held employee thank-you events, and has posted the Top Performer honor on flat screens throughout the facility and in publications.

“We were thrilled and are having a system-wide recognition,” Brennan said. “We’re acknowledging it and thanking people.”

Each hospital on the list of Top Performers on Key Quality Measures, about 18 percent of those reporting measures, met two 95-percent performance thresholds. They all achieved 95 percent or more on a single, composite score, which includes all the accountability measures for which it reports data to The Joint Commission, including measures that had fewer than 30 eligible cases or patients, and each facility met or exceeded 95 percent performance on every accountability measure for which it reports data to the accrediting body, excluding measures that had fewer than 30 eligible cases or patients.

Another 583 hospitals fell slightly short by missing 95 percent performance on only one measure. That happened to some UPMC hospitals in Pennsylvania, particularly with the incorporation of new psychiatric measures.

However, UPMC Horizon and UPMC McKeesport made The Joint Commission list in both years, and UPMC Northwest became a Top Performer this year.

“We have been focusing on core measures for more than five years, looking at every operational practice to get evidence-based medicine into place,” said Linda Harvey, a director in UPMC’s Donald D. Wolff Jr. Center for Quality, Safety and Innovation. “There is a lot of teamwork. And our culture has changed by becoming more proactive in incorporating evidence-based practice into process and technology.”

UPMC staff members look at every case that falls out of the desired metrics and then takes action to understand why it occurred and how best to prevent future fall outs. Facilities share successes and opportunities with each other. The health system benchmarks itself among its 20-plus hospitals, as well as other state and national hospitals and academic medical centers. UPMC is leveraging electronic health record (HER) technology to help clinicians gain easy access to evidence-based practices and information to make better point-of-care decisions.

Harvey reported that staff felt proud at being named a Top Performer and that patients are becoming more aware of public access to a hospital’s quality scores.

Likewise, so do staff at Prime Healthcare facilities, with eight hospitals named Top Performers.

“The Joint Commission recognition, which is based on unbiased and peer-reviewed analysis, is viewed by all health systems, hospitals and employees as benchmarks for healthcare excellence,” said Edward Barrera, corporate director of communications for Prime Healthcare Management, based in Ontario, Calif. “With this recognition, patients know that a hospital is focused on their care and quality outcomes.”

The Prime model is a dedicated physician-driven, patient-focused system, and physicians govern in all sectors of the management, Barrera said.

“We adhere to proven clinical protocols,” Barrera added. “We invest in infrastructure, such as upgrading information systems and capital improvements, which increases the quality of healthcare by using state-of-the-art technology.”

The new list of Top Performers increased more than 50 percent from 405 hospitals last year. All measures tracked during at least two years showed improvement from 2010 to 2011.

Noticeably this year, chain hospitals improved their outcomes. Ninety-six of HCA’s 135 hospitals are included among The Joint Commission’s list of Top Performers. Jonathan B. Perlin, MD, PhD, HCA’s chief medical officer and president of the company’s Clinical and Physician Services Group in Nashville, Tenn., credits the contributions of its employees and affiliated physicians with ensuring HCA continuously strives to attain and sustain clinical excellence.

“The 2012 results reaffirm the dedication to evidence-based care and positive patient outcomes that is shared by our physicians, nurses and other caregivers during 20 million patient encounters annually,” Perlin said in a written statement.

In addition to HCA’s impressive results, 50 hospitals owned by Community Health Systems of Franklin, Tenn., were recognized as Top Performers, as were 41 Health Management Associates of Naples, Florida, hospitals; and 20 Kaiser Permanente hospitals.

The Joint Commission said that although hospitals are doing better on most individual process of care measures, more improvement is needed.