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Hospital Accreditation Audience

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Performance Assessment of Three Hospitals

Performance assessment is the evaluation stage of quality management. Measurement is considered as the central aspect for the improvement of hospital quality as it provides the means for defining the actual activity of the hospitals and compares them with the original targets (Shaw & Carter). This helps to identify the improvement opportunities. Data of performance management is judged by comparison of the results to the performance expectations that are internally set and comparison of the results with the achievements of the other facilities (, 2016). This determines whether the performance is under statistical control. This assignment deals with the comparison of three hospitals in California with respect to the hospital compare website of CMS and the Joint Commission quality check website. Finally, from the consumer standpoint, it will be determined which website is the easiest for the consumers for the purpose of performance assessment.

CMS Hospital Compare Website

For this assignment, the three hospitals selected are Hoag Memorial Hospital Presbyterian (1), Saddleback Memorial Medical Center (2) and Mission Hospital Regional Medical Center (3). For the process of care measures, it is determined how well a hospital provides patient care and the patient records are converted into percentage or rate for assessing their performance. According to Medicare, the patients who are admitted to the hospitals for the purpose of treatment of their medical problems may sometimes get other complications and serious injurious that might even lead to death. Some patients experience other problems after their discharge that requires re-admission to the hospital. Such events can be avoided and prevented if the best practices are followed for the process of care measures. Two of the aspects are considered here for the complications that include surgical complications and healthcare associated infections. For surgical complications, the rate of complications for the patients of knee and hip replacements,  the value of (1) was not determined as the number of reported cases were too small and for (2) and (3), the rates were similar to the national rate.

Rate of Complications for knee and hip replacements

Figure 1: Rate of Complications for knee and hip replacements

Source: (2016)

For healthcare associated infections, the urinary tract infections that is catheter-associated in the selected wards and ICUs, (1) scored the highest rank while (2) and (3) scored similar ranks which were all lower than the national benchmark of 1.

 Urinary Tract Infection Complications

Figure 2: Urinary Tract Infection Complications

Source: (2016)

The outcome of care measures exhibits the care provided by the hospitals for getting the best results for the patients under certain conditions. This aspect of comparison helps in the understanding of the overall care provided to the patients in accordance with the recommended care by the hospitals. In this regard, stroke care has been compared for the three hospitals and the two parameters assessed were timely stroke care and effective stroke care. For timely stroke care, it was determined how quickly the patients of ischemic stroke received the medication for breaking up the blood clot within three hours of the starting of the symptoms. The scores for (1), (2) and (3) were found to be 98%, 90% and 100% respectively in comparison to the California and National rates of 89% and 84%.

Timely Stroke Care

Figure 3: Timely Stroke Care

Source: (2016)

For effective stroke care, it was determined the how frequently that the patients of ischemic stroke received the prescription medicines for prevention of the complications caused by the blood clots at the time of discharge. For all the three hospitals, the score was 100 against the state and national rates of 99%.

Effective Stroke Care

Figure 4: Effective Stroke Care

Source: (2016)

Regarding the patient’s experiences, the experiences of the patients are taken into account during their recent hospital stay. One of the aspects compared in this assignment is the rate of the patients who informed that their nurse communicated well every time they required any help. The scores of (1), (2) and three were 78%, 76% and 74% respectively against the state and national scores of 75% and 80%.

Patient’s Experience

Figure 5: Patient’s Experience

Source: (2016)

Joint Commission Quality Check Website

Quality check lists the accreditation status of the Joint Commission and it is solely for the purposes for comparison. Consumers should not rely on the information provided here for choosing a provider and are recommended for verification of its accuracy. A gold seal declares that quality of care has been emphasized on and the information is passed over to the competitors, staff, patients and the community (, 2016). Out of the two hospitals selected in this assignment, Saddleback Memorial Medical Center and Mission Hospital Regional Medical Center received the gold seal. The ratings were found to be quite similar to the CMS site however, they were not elaborate and no graphical representation was present. The reports were in the form of keys and the comparisons of the state and national wise were symbolic, instead of accurate digital representation. Detailed information was available only from the CMS Hospital Compare website as every aspect of patient care was taken into account while carrying out the comparisons. The Joint Commission Quality Check website provided only the general information without any elaborate detailing of the various situations when compared to the CMS website.

Consumers Standpoint

From the consumer standpoint, it is very much obvious that the CMS Hospital Compare website is the easiest for using for the purpose of performance assessment. This is because of the fact that it provides richer details and with a click on the particular subjects, the consumers are directed to the required information with graphical comparisons in an elaborate and lucid manner. The consumers can measure the quality of the hospitals based on the ratings provided by CMS. Every consumer can have access to the same data that can facilitate the discussions among the stakeholders of healthcare (Ross, 2013). It is beneficial for the healthcare consumers since they are reported and standardized every year and the measures that are not beneficial are withdrawn and uncovered. Improvement is spurred among the rated hospitals in their areas of lacking that provides the consumers with better healthcare services.



Hospital Accreditation Audience | Joint Commission. (2016). Retrieved 28 August 2016, from

Hospital performance assessment. (2016). Retrieved 27 August 2016, from

Medicare Hospital Comparison. (2016). Retrieved 27 August 2016, from

Ross, T. K. (2013). Health Care Quality Management: Tools and Applications. John Wiley & Sons.

Shaw, P. & Carter, D (2015). Quality and performance improvement in healthcare.

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