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Summary Quality Indicators


The Joint Commission is an organization that accredits hospitals and other healthcare organizations across the nation. The Joint Commission has selected certain quality indicators as “accountability measures”. We display Norton Healthcare’s results below.

The Joint Commission accountability composite rates (Overall and measure set specific)
TJC computes the accountability composite rate from 23 accountability measures (1-HF; 8-SCIP, 6-AMI; 3-PN; 3-CAC).  The TJC accountability composite rate combines the accountability measures from these 5 measures sets.  Elements include hf3, scipinf4, scipinf1a, scipinf2a, scipinf3a, scipcard2, scipvte2, scipinf6, scipinf9, ami1, ami3, ami2, ami5, ami7a, ami8a, pn3b, pn6a, pn6b, cac1a, cac2a, cac3. Accountability measures have been integrated into the information reported on Quality Check. However, the categorization of the measures into accountability and non-accountability measures will not affect individual measure information reported on Quality Check.(JC) Overall accountability composite (1-HF; 8-SCIP, 6-AMI; 5-PN; 3-CAC).  high 98.3 97.9 97.8 97.9 # 97.9   97.8
This indicator monitors the composite score on all 6 Heart Attack accountability measures. Accountability measures are quality measures that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement: Research (strong scientific evidence exists demonstrating that compliance with a given process of care improves health outcomes), Proximity (the process being measured is closely connected to the outcome it impacts; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs), Accuracy (the measure accurately assesses whether the evidence-based process has actually been provided), and Adverse Effects (the measure construct is designed to minimize or eliminate unintended adverse effects). AMI accountability measures' composite high 100 97 99 100Quality Ribbon   99 90 100
Number of heart failure patients with left ventricular systolic dysfunction (LVSD), a particular form of heart failure, per 100, who received an angiotensin converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB), a class of drugs used in the treatment of heart failure, at hospital discharge. This is the only Heart Failure accountability measure defined by Joint Commission. Accountability measures are quality measures that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement: Research (strong scientific evidence exists demonstrating that compliance with a given process of care improves health outcomes), Proximity (the process being measured is closely connected to the outcome it impacts; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs), Accuracy (the measure accurately assesses whether the evide nce-based process has actually been provided), and Adverse Effects (the measure construct is designed to minimize or eliminate unintended adverse effects). HF accountability measure composite (heart failure) high 97 93 100Quality Ribbon 96 # 97 94 97
This indicator monitors the composite score on all 3 Pneumonia accountability measures. Accountability measures are quality measures that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement: Research (strong scientific evidence exists demonstrating that compliance with a given process of care improves health outcomes), Proximity (the process being measured is closely connected to the outcome it impacts; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs), Accuracy (the measure accurately assesses whether the evidence-based process has actually been provided), and Adverse Effects (the measure construct is designed to minimize or eliminate unintended adverse effects). PN accountability measures' composite high 99 96 97 97 # 98 94 96
% of SCIP measure opportunities met (composite). This indicator also monitors the composite score on all SCIP accountability measures defined by Joint Commission. Accountability measures are quality measures that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement: Research (strong scientific evidence exists demonstrating that compliance with a given process of care improves health outcomes), Proximity (the process being measured is closely connected to the outcome it impacts; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs), Accuracy (the measure accurately assesses whether the evidence-based process has actually been provided), and Adverse Effects (the measure construct is designed to minimize or eliminate unintended adverse effects). SCIP accountability measures composite (surgical care improvement project) high 98 98 98 98 # 98 96 99
TJC computes CAC accountability composite rate from 3 CAC measures (cac1a, cac2a, cac3). CAC accountability measures' composite high         95.3 95.3   95.5

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