Hospital Information for the Public

Performance Reports

Performance reports are intended to be helpful in making judgments about potential providers of care. However, they should not serve as the sole basis for any decision. The information contained in performance reports, and the accreditation process in general, does not guarantee that a particular individual will receive quality care in a specific health are setting at a particular time.

Health care organizations request that the Joint Commission conduct an objective evaluation of their performance in relation to state-of-the-art standards of performance (to be a licensed hospital in the State of RI, Joint Commission accreditation is required). These standards relate to the quality of care being provided and are recognized by the Joint Commission and by the many health care experts and representatives of the public who contribute to their development as being achievable under ideal circumstances. The health care organization is assigned an overall evaluation score. An overall evaluation score is derived from an assessment of an organization's compliance with all applicable Joint Commission standards at the time of the full survey. It is based on a scale of 0 to 100, with 100 representing the highest possible score.

Performance reports take the summary form of an accreditation decision grid. The grid is a single page display of the performance areas that summarizes standards in each Joint Commission accreditation manual. Each score on the grid reflects an organization’s assigned level of compliance for standards relating to a key performance area. Performance areas are group standards considered to be critical to a hospital’s overall performance.

The organization of the decision grid corresponds to the organization of the standards. The decision grid is divided into the same three sections as the standards: Patient-Focused Functions, Organization Functions, and Structures with Functions.

Health care organizations are scored on a scale of 1 to 5. One is the best.

Upon review of an organization’s performance scores, it is important that the special nature of the Joint Commission scoring scale is understood. Health Care organizations are scored on a scale of 1 to 5, with 1 being the best. Definitions of the scores are as follows:

Score 1

• Substantial compliance means the organization consistently meets all the major provisions of the standards in this performance area.

Score 2

• Significant compliance means the organization meets most provisions of the standards in this performance area.

Score 3

• Partial compliance means the organization meets some provisions of the standards in this performance area.

Score 4

• Minimal compliance means the organization meets few provisions of the standards in this performance area.

Score 5

• Noncompliance means the organization fails to meet the provisions of the standards in this performance area.

NA

• Not applicable indicates that the performance area does not apply to the organization.