The Joint Commission 2016 quality report shows gains, emphasizes easier reporting options

Hospitals have made significant progress in meeting quality measures newly added to The Joint Commission’s (TJC) annual report, and many measures have been retired due to hospitals meeting them so successfully. More flexible options for performance reporting that better align with CMS’ Hospital Inpatient Quality Reporting Program were implemented to ease reporting burdens, and TJC is committed to continually providing quality improvement resources for hospitals. In America’s Hospitals: Improving Quality and Safety – The Joint Commission’s Annual Report 2016, measures for inpatient psychiatric services, tobacco use treatment, substance use care, and influenza immunization have shown significant gains.


In 2015, TJC introduced flexible options for reporting electronic clinical quality measures (eCQMs) and chart-abstracted measures. The Pioneers in Quality™ program was introduced and coordinated with the Core Measure Solution Exchange® in order to support hospitals transitioning to eCQM reporting. The Pioneers in Quality program provides resources to hospitals, including educational content, an advisory panel, and outreach. The Core Measure Solution Exchange is a collaborative online network developed for TJC-accredited hospitals to promote performance measurement success stories.


TJC uses a composite score result that sums up individual results into a summary score in order to demonstrate improvement. The overall composite score declined from 97.2 percent in 2014 to 93.7 in 2015 due to the retirement of high-scoring measures, resulting in some difficulty in comparing results.

The inpatient psychiatric services composite score, made up of several underlying measures from admission screening to multiple antipsychotic medication justification, has improved by 3 percentage points since 2011, ending at 90.3 percent for 2015. The stroke care composite score was already high at 94.9 percent in 2011, but has improved to 97.7 percent. Perinatal care scores have improved drastically since 2011, from 53.2 percent to 97.6 percent. Tobacco and substance use treatment and care results have only been measured for two years, but have seen gains of several percentage points in all measures.