Big Names Missing From List of Best Hospitals


The Joint Commission issued a list of what it is designating as the top-performing hospitals in America, and the facilities that are not listed may be somewhat surprising.

The Commission, which accredits some 4,000 hospitals in the United States, created a new designation for hospitals last year, to recognize the ones that are “the best of the best” in terms of quality, said Dr. Mark R. Chassin, president of the Joint Commission.

Out of the 3,000 hospitals for which the Joint Commission has been collecting performance data on for the last decade, 405 met the top performance criteria for data reported in 2010. They represent only 14% of the universe of facilities that the Joint Commission accredits.

These hospitals had a 95% score on a composite measure for all 22 performance measures for heart attack, heart failure, pneumonia, surgical care, and children's asthma care. The hospitals also met a second 95% target for each individual measure, which means “a hospital provided an evidence-based practice 95 times out of 100 opportunities to provide the practice,” according to the Joint Commission.

The 405 that made the cut were primarily small and rural, leading to questions from reporters as to why some of the bigger and better-known academic and urban medical centers, all having stellar reputations, did not achieve the ranking of a top performer. Dr. Chassin replied, “Reputation and performance on important measures of quality don't often go together.”

Missing from the list are such well-known facilities as Johns Hopkins, Duke, the Cleveland Clinic, the Mayo Clinic, M.D. Anderson, and even the Geisinger Health System, which has been hailed as a quality pioneer.

Dr. Chassin said that the Commission's use of process measures, instead of outcomes measures, was the best way to determine quality of care.

Overall, hospitals are doing much better at meeting these measures, said Dr. Chassin. But he added, “Hospitals can and should do better.”

Among the improvements tallied by the Joint Commission in its annual report on quality:

▋ Hospitals provided an evidence-based heart attack treatment 984 times for every 1,000 opportunities to do so, for a composite score of 98.4%. That's up from 86.9% in 2002.

▋ The surgical care score improved from 82.1% in 2005 (when it was added) to 96.4%.

▋ A total of 91.7% of hospitals achieved 90% or better on the overall composite score, up from just 26.2% in 2002.

Hospitals are still lagging in two areas. Only 60% are hitting the 90% target for providing fibrinolytic therapy for acute MI within a half hour of arrival. And 77% are reaching the 90% compliance goal for administering antibiotics to ICU pneumonia patients who are immunocompetent.

Starting in 2012, hospitals seeking accreditation will be required to hit 85% or better on a new composite measurement for performance on accountability measures. Dr. Chassin estimated that currently, 121 hospitals would not hit that target.

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Quality's in Outcomes, Not Process

Given that the “quality” we are talking about here is measured by process documentation (not actual outcomes), the smaller the hospital and number of documenting physicians, the more likely you are to see percentages of “quality” in the upper echelons. In other words, the process may be occurring in the larger hospitals, it is just not getting documented as such. … Smaller hospitals can create uniform documentation standards a lot faster than larger hospitals.

It is a bit disingenuous for Dr. Chassin to suggest that reputation and performance do not often go together. In the case of the Cleveland Clinic, Johns Hopkins, Duke, and other similar centers, it most certainly does and has been shown in direct outcomes measurement.

You will notice that Lakewood Hospital in Lakewood, Ohio, is the only Cleveland-area hospital that is in the upper echelon in process measurement for acute MI as listed by the Joint Commission (as it is, Lakewood Hospital is owned by the Cleveland Clinic and is a member of the Cleveland Clinic Health System), but if, because of this “best of the best” list, a complicated patient with an acute MI chooses to go to Lakewood Hospital over going to a tertiary center with outcomes reported as good as the Cleveland Clinic main campus, then the Joint Commission should be ashamed of itself.

FRANKLIN A. MICHOTA, M.D., is director of academic affairs in the department of hospital medicine at the Cleveland Clinic.

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