In order to compare its performance and to identify opportunities for improvement, a Hospital needs a mechanism for comparing its performance to that of other similar hospitals locally, nationally, and internationally with recognised, internationally accepted standards.

The mechanism must be designed to transform input forces and movement by (i) operate or interact by participating in external performance databases, (ii) compare its performance to that of other similar hospitals,  into a desired set of output forces and movement when the hospital can identify opportunities for improvement and hence documenting its performance level.

This arrangement of connected parts in a system of parts of individual hospital performances like those parts of a machine is surely an effective tool to demonstrate the quality and safety that are being provided in the hospital and can be thought of as benchmarks of success when the hospital participates through reference databases.

I can think of the following initiatives in the US when hospitals as providers participate through reference databases to improve by benchmarking their performance against others, encourage private insurers and public programs to reward quality and efficiency, and help patients make informed choices:

1. Hospital Compare which encourages hospitals to improve the quality of care they provide and for patients to find hospitals and compare the quality of their care  and make decisions about which hospital will best meet their health care needs;
2. Quality Improvement Organization (QIO) – a private, mostly not-for-profit contractor of the Centers for Medicare & Medicaid Services (CMS) to improve the quality of health care for all Medicare beneficiaries;
3. ORYX® data reported on The Joint Commission website at Quality Check® which permits user comparisons of hospital performance at the state and national levels; and
4. hospitals complete The Leapfrog Hospital Survey, the gold standard for comparing hospitals’ performance on the national standards of safety, quality, and efficiency

In all instances, hospitals need to check if they are required by local laws or regulations to contribute to some external databases. Hospitals also need to maintain security and confidentiality of data and information at all times when operating or interacting with external databases.

ff your hospital is a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, then the JCI Standard MCI.20.2 requires it to have a mechanism in place with the following characteristics:

1. there is a process to participate in or to use information from external databases, thus satisfying the JCI Standard QPS.4.2, ME 2 which states that “Comparisons are made with similar organizations when possible.”;
2. the hospital contributes data or information to external databases in accordance with laws or regulations, thus satisfying for example both the JCI Standard PCI.10.4, ME 1 which states that “Health care–associated infection rates are compared to other organizations’ rates through comparative databases.” and the JCI Standard QPS.4.2, ME 2; and
3. the hospital compares its performance using external reference databases, also satisfying the JCI Standard QPS.4.2, ME 2; and the hospital maintains security and confidentiality when contributing to or using external databases.

References:

1. Facts about ORYX® for Hospitals (National Hospital Quality Measures), The Joint Commission, viewed 8 March 2013, < http://www.jointcommission.org/facts_about_oryx_for_hospitals/ >
2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
3. Prathibha, V (ed.) 2010, Medical quality management : theory and practice, 2nd edn,  Jones and Bartlett Publishers, Sudbury, MA, USA
4. Quality Improvement Organizations, Centers for Medicare & Medicaid Services, viewed 6 March 2013, < http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs/index.html?redirect=/qualityimprovementorgs >
5. Welcome to the Leapfrog Hospital Survey, The Leapfroggroup, viewed 8 March 2013, < https://leapfroghospitalsurvey.org/ >