The data in the performance measure download file includes hospital demographic information, the hospital’s Medicare Provider Number and Joint Commission ID number, and its performance measure rates and comparisons. The user may request the performance measure data in a quarterly data point report or an annual aggregate report. The user may also select the data to be downloaded in a spreadsheet format (.xls), a tab delimited file (.txt) or a preformatted PDF report. Data dictionaries for each type of report and file format are available to assist the user in understanding the record layout, the data definitions and the data values.

Select a Data Dictionary from the following: Updated October 2008 (Requires Adobe Reader)

• Data Dictionary for the Quarterly PDF File Format
• Data Dictionary for the Quarterly xls and .txt File Formats
• Data Dictionary for the Aggregate PDF File Format
• Data Dictionary for the Aggregate xls and .txt File Formats

The Joint Commission’s performance measurement data is organized into core measure sets, each of which relates to a condition of care. The core measure sets included in the download are acute myocardial infarction (AMI), heart failure (HF), pneumonia (PN), pregnancy (PR), and surgical infection prevention (SIP). Hospitals are required to pick a subset of these measure sets to report to the Joint Commission. Currently hospitals are required to pick a minimum of three measure sets and submit data for all the measures within a measure set. Hospitals submit data to an intermediary called a performance measurement system. The measurement system aggregates a hospital’s data and sends this aggregated data to the Joint Commission quarterly. The Joint Commission then aggregates this quarterly data over the last four reported quarters for reporting on Quality Check.

The Joint Commission uses two types of measures to report National Quality Improvement Goal results: process measures and outcome measures.

Process measures describe how often a series of recommended activities, actions, or steps are done (for example, a treatment such as aspirin at arrival) in a patient population over a set time period. Process measures are expressed in terms of a percentage, or rate. The denominator is the total number of patients for whom the treatment or event was recommended.

Outcome measures describe the end results of a function or process in a patient population over a set period of time. Outcome measures are expressed in terms of a percentage or rate. The denominator is the total number of patients at risk for the outcome.

Included in the download is the following:

1. Hospital Results - Symbol
   The symbol represents the comparison of the hospitals performance for the measure to the national average at the measure and measure set level.
   
2. Hospital Results – Number
   The number of times as a percentage the hospital performed the measure during the time period being reported.
   
3. Total Patients
   The total number of patients treated for the measure.
   
4. Nationwide - Average Rate
   The average rate for all Joint Commission accredited healthcare organizations in the nation that provide results for a measure. The average rate is calculated by dividing the total number of patients who had the recommended care provided for a measure by the total number of patients who met the inclusion and exclusion criteria for that measure in the timeframe being reported.
   
5. Nationwide - Top 10%
   Scored at Least: The number of times, as a percentage, the top 10% of all Joint Commission accredited hospitals in the nation followed the recommended treatment/ procedure during the time period being reported.
   
6. Statewide - Average Rate
   The average rate for all Joint Commission accredited healthcare organizations in the state that provide results for a measure. The average rate is calculated by dividing the total number of patients who had the recommended care provided for a measure by the total number of patients who met the inclusion and exclusion criteria for that measure in the state for the timeframe being reported.
   
7. Statewide - Top 10%
   Scored at Least: The number of times, as a percentage, the top 10% of all Joint Commission accredited hospitals in the state followed the recommended treatment/procedure during the time period being reported.
   

Uses of Quality Check Data

Quality Check data includes national rates, state rates, and hospital rates at the measure level. Data can be analyzed in many ways. Comparisons can be made from the hospital to national/state level. Comparisons between hospitals can be made. Hospitals with known similar characteristics can have their rates combined and compared to various benchmarks, either provided by the Joint Commission data download or to an outside credible source. Valid comparisons must be consistent using the same measures.

Misuses of Quality Check Data

Proper care needs to be taken into consideration when analyzing Quality Check data. Analysis of the data should incorporate the proper distribution of the data. Some analysis may require the use of a Binomial Distribution, Chi-Square Distribution, or Normal Distribution. Using a wrong distribution will yield incorrect inferences about a hospital’s level of care. Another source of error is to use different measures in making comparisons from one hospital to another. Process measures should be compared with process measures and not to outcomes measures.

The Joint Commission is a recognized and award winning international leader with a long proven ability to identify, test and specify standardized performance measures. It engages in cutting edge performance measurement research and development activities, and has established successful, ongoing, collaborative relationships with key performance measurement entities. The Joint Commission presides over a growing, national, comparative performance measurement database that can inform internal health care organization quality improvement activities, external accountability, pay for performance programs and advance research.

Technical reference information on core measures:

• Future Versions of the Specification Manual for National Hospital Quality Measures
• Comprehensive Review of Hospital Core Measures

Q.	Why will my report not download even though I see the “Report is being Generated” window?
A.	Some newer browsers have a new security enhancement which requires you to click an option before the download can occur. In the case of Internet Explorer, you may see a yellow highlighted area on your window, see figure below. You will need to click on this area and select the Download File option. Now you should be able to receive your report.
Q.	What is performance measurement data?
A.	Performance measurement data reports on National Quality Improvement Goals (NQIGs) for hospitals only. These goals allow hospitals to report on key quality of care indicators in up to five treatment areas: heart attack, heart failure, community acquired pneumonia, pregnancy and related conditions, and surgical infection prevention. These conditions are the most common reasons that patients go to the hospital and they affect hundreds of thousands of patients each year. Patients who are treated according to these guidelines are more likely to improve or and have good outcomes of care. As more measures are approved and endorsed by the National Quality Forum (NQF), the Joint Commission will explore ways to incorporate that data in Quality Reports.
Q.	Why are National Quality Improvement Goals important?
A.	Health care providers and practitioners recognize these as "desirable goals" for treating patients with the identified conditions. For example, these are a few of the Quality Improvement Goals a hospital should follow for patients who suffer a heart attack: Receive aspirin within 24 hours before or after hospital arrival. Assure that the patient is discharged from the hospital on aspirin. Give the patient advice and education to stop smoking. Give the patient a prescription for a beta blocker. Other conditions might prevent certain treatment for a patient. The patient should discuss these matters with his/her doctor.
Q.	How are the data collected?
A.	Hospitals submit data to an intermediary called a performance measurement system. The measurement system aggregates a hospital’s data and sends this aggregated data to the Joint Commission quarterly. The Joint Commission then aggregates this quarterly data over the last four reported quarters for reporting on Quality Check.
Q.	How are the results calculated?
A.	National Quality Improvement Goals are calculated for requirements that relate to treatment of a specific type of condition, such as heart attack. The hospital's results are compared to other hospitals that report on the same condition and requirements. The results are analyzed and displayed using symbols to indicate the level of performance. Results are reported by symbols and comparative scores. Results for the past four quarters for the measure are totaled and the average result is calculated. The calculated result for the hospital is compared to the results of all other hospitals that have reported on this condition and related requirements. An organization's results are reported in comparison to all Joint Commission-accredited hospitals in the nation and to all Joint Commission-accredited hospitals in the state.
Q.	Are all hospitals required to report on core measure data?
A.	No, they are not. Organizations such as pediatric, psychiatric and small rural hospitals are not required to submit core measure data due to their size and / or patient populations.
Q.	What would cause a report file to be blank?
A.	You will receive a blank report file if a state you selected does not contain results for a measure set or measure you selected. The measure set selection screen shows the measure sets available in the state or states you selected. If you selected multiple states, a measure set may be reported in some of the states but not all. A blank report file will be created for every selected state that did not also contain the selected measure sets or measures.