TJC annual report shows safety improvement

620 hospitals named top performers

The 5th annual Joint Commission (TJC) report on patient safety, "Improving America's Hospitals: The Joint Commission Annual Report on Quality and Safety 2012," presents proof positive that hospitals are getting the quality message that TJC wants them to learn. This year, it lists more than double the number of top performing hospitals as in 2011, with 620 of the more than 3,300 hospitals submitting data to TJC achieving that status. To gain such recognition, they must score 95% or better on both the composite score from all the measures, and for every measure for which there are more than 30 eligible cases or patients.

While just under a fifth of reporting facilities were top performers, the vast majority — just under 89% — had a composite score of at least 90%, more than four times the total that reached that level a decade ago.

The number with the 90 or above composite score might have been higher, but the 2012 report includes new measures for inpatient psychiatric, stroke, and venous thromboembolism (VTE) care, whose addition resulted from the 91.7% that got a 90 or above composite score last year.

Another 583 hospitals were just short of making the Top Performer mark by missing the 95% cutoff on a single measure.

All of the measures tracked for more than a year have shown improvement over the last 12 months. Most of the measures are well into the 90-100% category. The new measures, though, lag a bit but still show improvement. VTE care is up 7.2 points to 89.9%; stroke care is up 2.2% to 94.9; and inpatient psychiatric services is up from 80.5% two years ago to 87.3 in this past year.

While maybe a third of the reporting hospitals show themselves to be astonishingly safe facilities worthy — or very nearly worthy — of being called a top performer, it's by no means an easy designation to get, say Jerod Loeb, PhD, executive vice president for the division of healthcare quality evaluation at TJC.

Indeed, if you look at the lists of top hospitals that make it into consumer publications, few of those facilities make the grade in TJC's annual report. "The academic medical centers are under-represented here, although there are more of them this year than last." Their representation actually increased by half — from 6% of the top performers to 9%.

But the fact that relatively few academic medical centers are listed is of interest. Loeb says they are very large organizations with huge staff and vast numbers of patients. Getting something right 95% of the time, and remembering to document that you did so, seems to be much harder for those large organizations. While many large hospitals will note that they serve much sicker patients, Loeb says that won't fly with these measures, because none of them are related to severity of illness.

As a cancer patient, Loeb says he has experienced care in both a large cancer center and a small community hospital. "I think it's easier in the latter to get things done. My hope is that this will be a stimulus to those bigger facilities to talk more about how to ensure the mundane stuff gets done and documented, like getting aspirin or beta-blockers to the appropriate patients in a timely manner."

And while Loeb encourages organizations to talk to each other to find answers to some of the problems they encounter — there are solution sharing opportunities through the Joint Commission website — he is a firm believer that "when you've seen one institution, you've seen one institution. When you have a vexing problem in healthcare, the reasons at one hospital might be different than another. If you don't find the reason behind the failure specific to your facility, then your solution will be a failure."

For example, if hand-washing is a concern, maybe you find that placement of the hand sanitizer is a problem. So you place it near the entry and exit of the room and expect your compliance to go up, particularly if that worked at a facility like yours. But if you don't consider issues specific to your hospital — like having someplace for a nurse or doctor to put a chart so they can use the dispenser — then simply moving your hand sanitizer dispensers won't help solve your problem. "The old notions of best practices working everywhere doesn't hold," he says.

For those who still need to get that last little bit up to 95% and beyond, Loeb says to do a root cause analysis for even the everyday things. "Most of the time, they save root cause analysis for tragedies and sentinel events," he says.

Loeb says the 95% bar is high, but he knows that if there are 95 patients getting what they need every time, then there are five others who aren't. "Put yourself in the mind of a CEO who is being asked to defend not getting it right all the time," he says. "We have seen steady increases, predating a connection to incentive payments and public reporting. I think that for now, this is fine, but in a year or two, I bet the rules will be tighter. I would love to see some sort of reward for hitting that 100% mark, but at the end of the day, healthcare is local and a uniquely human endeavor."

What's it take to be the best?

Just getting to that 95% bar is difficult enough, and takes everyone in a facility working together. The more people you have, the harder that is, says Donna L. Zubay, BSN, MBA, CPHQ, chief quality officer and facility compliance officer at Oro Valley (AZ) Hospital. "If you have a constant rotation of new people and residents, it must be hard to achieve this kind of goal," she says. For her facility, it took having hospitalists on board, seeing pretty much every heart failure and pneumonia patient.

Zubay says the hospital uses an EMS provider whose staff relay what's going on in the field to the medical personnel at the hospital. They have built a level of trust over the years that allows the physicians to trust the technicians bringing in the patients implicitly. They work together to ensure that standards related to something like cardiac or stroke care are met on time for every single appropriate patient.

Despite being a top performer, Zubay says she still watches the new measures related to stroke and VTE carefully. "Getting the registration piece done quickly enough to get someone to the cath lab or whatever is tough." The hospital has been in the high 90s for most measures for a while. Getting to 100 is tough. For a 144-bed facility with an average census in the 60s, there are some kinds of cases and patients that are rare. Miss something on a single door-to-balloon measure or ACE or ARB inhibitors on discharge for one patient and you risk going below that 95% level, let alone the perfect mark.

She says constant teaching from the quality department and auditing of patient charts while the patient is still in the hospital helps them continue to perform at an exceptional level. "Concurrent auditing is important. If you don't know if you need some information in the chart — the injection fraction for a heart failure patient that might have been done in the cardiologist's office before admission, for instance — you have a problem. Knowing something is missing after the patient leaves is too late."

She also makes it a point to tell physicians or nurses whenever something from one of the measures is missed or is missing. "We talk about this stuff regularly," says Zubay.

Another Top Performer, Bon Secours Maryview Medical Center in Portsmouth, VA, puts its excellence down to involving everyone from food service to contractors in quality and quality improvement, says Warren Austin, MD, chief medical officer for the facility. "Someone from security may help the pneumonia team. Everyone is a part of our culture of excellence."

And while Austin says he knows the hospital is an outstanding facility, there was still an element of surprise at being named among the best of the best. "But while getting awards is great, great care is better."

The hospital aims for 100% on every single core measure, he says. "If you are at 61 minutes for pre-surgical antibiotics, you fall out of that 100%. It doesn't matter if it was because of some surgical delay or other uncontrollable reason. There are a lot of moving parts and you have to have everyone involved, everyone playing a part."

A current goal for Bon Secours Maryview is zero healthcare-acquired infections. "Sick people come to the hospital and spread their germs," Austin says. "We work towards zero, we shoot for the moon, but it's very hard." And while 99% seems like a great score for an algebra test, he says they don't celebrate for anything less than perfect. "We might share that something is 97%, but there is no party."

Indeed, make it a point to remind your staff what 95% really means, says Ruth Ragusa, RN, vice president of organizational effectiveness at South Nassau Community Hospital in Oceanside, NY. "If you or your mother or your child were one of the 5% that didn't get some treatment or care in the right amount of time, you'd be concerned. If you present this to your staff and they applaud the 95%, remember to remind them that of those 1,000 patients, 50 didn't get the very best care. Remember the ones you miss."

For more information, please contact:

  • Jerod Loeb, Ph.D., Executive Vice President, Division of Healthcare Quality Evaluation, The Joint Commission, Oakbrook Terrace, IL. Email:
  • Donna L. Zubay BSN, MBA, CPHQ, Chief Quality Officer and Facility Compliance Officer, Oro Valley Hospital, Oro Valley, AZ. Telephone (520) 901-3608. Email:
  • Warren Austin, MD, Chief Medical Officer, Bon Secorus Maryview Medical Center, Portsmouth, VA. Telephone: (757) 398-2200.
  • Ruth Ragusa, RN, Vice President of Organizational Effectiveness, South Nassau Community Hospital. Oceanside, NY. Telephone: (516) 632-3999.

Bon Secours hospital gains recognition

The same week that Bon Secours Virginia Health System got the news that one of its hospitals was named a Top Performer by the Joint Commission (see story above), it got news that another of its facilities, Bon Secours Mary Immaculate Hospital in Newport News, VA, achieved a long-held goal: to reach Pathway To Excellence designation by the American Nurses Credentialing Center (ANCC), indicating it has created a positive work environment for its nurses as determined by a rigorous review process. It is the third hospital in Virginia to achieve the designation. All three are Bon Secours facilities.

The facility had to show it had implemented 12 quality initiatives that research shows make a difference to both the nurses working at a facility and their patients. Those standards are:

  • nursing control of nursing practices;
  • a safe work environment;
  • systems to address patient care and practice concerns;
  • a good orientation program;
  • a qualified CNO who participates at all levels of the organization;
  • professional development that is available and utilized;
  • fair compensation;
  • recognition for nursing achievements;
  • work-life balance is encouraged;
  • an emphasis on collaborative relationships;
  • competent and accountable nurse managers;
  • evidence-based practices and robust quality improvement program.

It took two years to complete the process, including an application, the compilation of reams of documentation, review by an accrediting commission, and a survey of nurses that at least 51% of them had to return and whose result must be at least 75% positive. Jeff Doucette, MS, RN, vice president of patient care services and chief nursing officer, says that they had a 69% participation rate and "great" positive responses.

The designation lasts for three years, and is often the first step an organization takes on its path to Magnet status, also awarded by the ANCC. "Hospitals that meet this criteria have better outcomes, better patient and physician satisfaction with the quality of nursing care, and a recognized positive work environment for nurses," he says. "This is the only organization and program that links the nursing experience to outcomes."

Doucette encourages other organizations who believe they have a great nursing staff to look at the program and consider going through the process. Even smaller facilities for which Magnet status isn't a good fit can take this step in adopting the foundational core of the Magnet program, he says. "Pathways offers you a chance to let your staff know — and the community you serve know — that you value your nurses and understand that what they do impacts patient outcomes.

Doucette says Mary Immaculate will continue to work toward Magnet recognition, and is thrilled to reach this point on the journey. "As an early adopter of the Pathways program, we want to get the word out about it. This is the validation of what we have invested in our nursing team and its development."