The Joint Commission touted the value of the metrics underlying its annual list of top-performing hospitals, saying the measures continue to play an important role in motivating quality improvement, while some hospitals left off the list are questioning its relevance.

The list reflects performance on evidence-based care processes, such as ensuring a heart-attack victim quickly receives aspirin inside an emergency room. The 405 hospitals that made the cut scored at least 95% on two commission-established thresholds and also attained a 95% or more on a composite score that included all accountability measures reported to the commission. Those represent 14% of the 3,000 accredited hospitals that report the data to the commission in 2010.

Hospitals overall showed improvement in care since 2002, when they scored 81.8% on the Joint Commission's composite measure, based on 957,000 opportunities to perform the care processes. In 2010, hospitals scored 96.6% on the composite metric with 12.3 million opportunities to do things right (the numbers of hospitals and measures have increased).

“Most recognize they are performing reasonably or very well on accountability measures, but there's still room for improvement,” Dr. Mark Chassin, the commission's president, said in a conference call with reporters.

The Joint Commission does not publish a list of hospitals that fail to make the cut. Unlisted hospitals will know what improvements they need to make, Chassin said. “Our aim here is to galvanize improvement and provide positive incentive for improvements.”

Meanwhile, starting in January, the commission said any hospital that attains a composite score below 85% would risk losing accreditation. That was the case for 121 hospitals measured in the 2010 data.

Some familiar names with reputations as leaders in quality, including Johns Hopkins Hospital in Baltimore and the Mayo Clinic in Rochester, Minn., were excluded from the list of top performers.

Chassin conceded larger teaching facilities were underrepresented, while small rural hospitals made up 22% of the list. The smaller hospitals were overrepresented compared with their distribution among Joint Commission-accredited organizations, he said. That's partially because it's easier for facilities with fewer patients to adhere to the standards, but he added that larger hospitals have better resources. Major teaching hospitals made up 5% of the list.

“Reputation and performance on important measures of quality do no always correlate,” Chassin said. The report, he said, should serve as a “wake-up call” for many large, renowned hospitals. He noted that 909-bed Cedars-Sinai Medical Center in Los Angeles did make the list.

Dr. J. Michael Henderson, chief quality officer at Cleveland Clinic, said his hospital and other larger facilities are well aware of the need for improvement: “I think we're wide awake.” Henderson said he's not surprised by Cleveland Clinic's exclusion. Echoing Chassin's assessment, Henderson said the three smaller Cleveland Clinic branches that made the list were the beneficiaries of smaller patient volumes.

Henderson questioned the relevance of the Joint Commission's rankings: “They're important, and we do pay a lot of attention to them, but they are a small bit of the big picture.”

While the Joint Commission's rankings were pioneering, Henderson said, new metrics are better, and the commission's statistics have “lost their basic value.” He recommended hospitalcompare.hhs.gov as a superior guide, and said researchers would follow the lead set by HHS and focus on more outcome-based metrics. Henderson did praise the commission's Center for Transforming Healthcare, which develops solutions for safety and quality issues.

Brock Slabach, senior vice president for member services for the National Rural Health Association in Kansas City, Mo., said rural facilities have the benefit of flexibility and less red tape.

Another advantage for rural providers is they treat their neighbors and friends, Slabach said. “It's a lot more personal, I'm not saying it's not personal in an urban area, but there's a lot more ownership from top to down in terms of the care provided.”