University of Michigan Health System receives high marks in quality care on Joint Commission and Hospital Compare (Medicare/Medicaid) Web sites.
BACKGROUND
The Joint Commission is an independent, not-for-profit association that evaluates and accredits nearly 15,000 health care organizations and programs in the nation. The Joint Commission’s goal is to continuously improve the safety and quality of health care provided to the public. It does this by conducting on-site surveys as well as quarterly evaluations of core measures data. In addition, the Center for Medicare and Medicaid Services promotes quality care for its beneficiaries. This is accomplished by on-site surveys and quality reporting methods similar to those used by the Joint Commission. By publishing results of their surveys and quality evaluations on public Web sites, the Joint Commission and CMS together provide consumers with information that helps them make important health care decisions.
The Joint Commission Quality Report and the CMS Hospital Compare Web site both reflect UMHS quality measures data that are submitted on a quarterly basis. Currently, organizations seeking evaluation are required to report on four of six official core measure areas:
- acute myocardial infarction (heart attacks)
- heart failure
- pediatric asthma
- pneumonia care
- pregnancy-related conditions
- surgical care improvement prevention
The Joint Commission and CMS quality reports for each organization are determined by measuring the self-reported results on standardized, evidence-based performance measures that all organizations are expected to follow. These reports are available online in a format that allows health care consumers to review and evaluate an organization’s success within these core measure areas.
DATA
The UMHS has shown excellent performance in the overall comparison of national and state CMS and Joint Commission-accredited organizations for its four reported core measure areas: acute myocardial infarction, heart failure, pneumonia care and surgical care improvement prevention. UMHS ranked above the national and state averages in 20 of the 23 reported quality indicators for these core measures.
UMHS achieved the ranking of “Best Possible Results” from the Joint Commission for three of these indicators: oxygenation assessment (a measurement in blood oxygen) in Pneumonia Care and beta-blocker medication prescribed and aspirin prescribed at discharge for Acute Myocardial Infarction Care.
The remaining three quality indicators had a performance that ranked close to the national average, leaving the UMHS with some improvement opportunities.
Here are the complete results of how UMHS performed on core measures for the October 2005 through September 2006 discharges:
Acute Myocardial Infarction (Heart Attacks):
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100% of eligible patients received an aspirin at arrival.
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99% of eligible patients received a beta-blocker (medicines that have been shown to increase life expectancy in heart attack patients) at arrival.
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100% of eligible patients received a PCI (percutaneous coronary intervention that opens blocked blood vessels and prevents further heart damage) within 90 minutes of arrival.
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Eligible patients received fibrinolytic (clot dissolving) medication within 30 minutes of arrival is an additional measure. UMHS provides PCI procedure for these patients instead of fibrinolytic medications.
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98% of eligible patients received smoking cessation advice/counseling.
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100% of eligible patients received an aspirin prescription on discharge.
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97% of eligible patients with left ventricular systolic dysfunction (heart failure) received an ACE inhibitor or ARB (medicines that have been shown to increase life expectancy in patients with heart failure) prescription on discharge.
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100% of eligible patients received a beta-blocker (medicines that have been shown to increase life expectancy in heart attack patients) prescription on discharge.
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UMHS’s inpatient risk-adjusted death rate from heart attack is similar to the national average of 16%.
Heart Failure Care:
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100% of eligible patients received an LVEF (testing of the heart’s pumping function)
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96% of eligible patients received an ACE inhibitor or ARB (medicines that have been shown to increase life expectancy in patients with heart failure) prescription on discharge
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96% of eligible patients received smoking cessation advice/counseling
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96% of eligible patients received disease specific and self-care instructions on discharge
Pneumonia Care:
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100% of eligible patients received an oxygenation assessment
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90% eligible patients received smoking cessation advice/counseling
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73% of eligible patients received their initial antibiotic within 4 hours after arrival
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85% of eligible patients received the most appropriate initial antibiotic
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92% of eligible patients received a blood culture test prior to the administration of antibiotics
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80% of eligible patients were screened for and received the flu vaccination
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83% of eligible patients were screened for and received the pneumonia vaccination
Surgical Care Improvement Program (prevents complications from specific surgeries):
- 94% of eligible patients received a preventative antibiotic(s) one hour before incision.
- 97% of eligible patients received the appropriate preventative antibiotic(s) for their surgery.
- 76% of eligible patients had preventative antibiotic(s) discontinued within 24 hours after surgery (within 48 hours for cardiac surgeries).
WHAT THIS MEANS FOR PATIENTS
These data show that patients with medical conditions that include them in any of the core measures quality sets are more likely to receive evidence-based medical care that is better than or equal to most national and state-accredited hospitals. In addition, the Joint Commission Quality Report and the CMS Hospital Compare Web sites offer patients information that allows them to make more informed health care decisions. UMHS’ high marks demonstrate its longstanding commitment to accurate data measurement and quality improvement and maintain its status as one of the best hospitals in the country.
UMHS patients can be assured that they will continue to receive high-quality care as the health system remains devoted to self-evaluation and ongoing patient care improvements while moving toward a goal of achieving 100 percent compliance on all quality indicators during future evaluations.
FOR MORE INFORMATION
To view the Joint Commission online Quality Report, visit the “Quality Check” section on the Joint Commission's Web site.
To view CMS’s hospital quality rankings Web site, visit the Hospital Compare Web site and search for the “University of Michigan.”
For more information about the Joint Commission, CMS and UMHS, contact Sharon Van Riper, M.S., R.N., C.C.R.N., Quality Improvement coordinator, at 734-615-9747 or via e-mail at sharonv@umich.edu.
To learn more about how the University of Michigan is committed to quality and appropriateness, contact John E. Billi, M.D., Associate Dean for Clinical Affairs, University of Michigan Medical School, at 734-936-5214 or Darrell Campbell Jr., M.D., Chief of Staff, University of Michigan Health System, at 734-936-5814.
For more detailed information on the medical terms used in this article, go to the University of Michigan Health Topics A to Z Patient Education Web site. 
July 2007
