Dr. Ahmed Nawaz, left, talks with his partner Dr. Neeraj Chopra at Holy Cross Hospital in Silver Spring. (James M. Thresher/THE WASHINGTON POST)

When the Joint Commission — the main accreditation organization for U.S. hospitals — issued its first listing of “top performers” this month, many health-care leaders were surprised to see that Johns Hopkins Hospital did not make the list of 405 institutions.

Neither did the Mayo Clinic or Massachusetts General Hospital. In fact, the commission’s list left out virtually all the country’s big-name medical centers, including those in the Washington area. Only one local facility made the cut: Holy Cross Hospital in Silver Spring.

The hospitals were rated not on high-tech treatments or cutting-edge research but on how reliably they followed recommended protocols for treating five of the most common conditions for which people are hospitalized: heart attack, heart failure, pneumonia, surgical infection and children’s asthma.

The hospitals were judged, for example, on how often they gave aspirin on arrival to heart attack patients, gave pneumonia and flu vaccines appropriately, and provided proper treatment to prevent blood clots.

These measures were chosen because they are evidence-based treatments that directly improve outcomes for patients, said the commission’s president, Mark Chassin. In addition, he said, many of the measures are identical to pay-for-performance requirements in federal and state programs as well as many private payers.

Numerous hospital-rating systems exist, but this is the first time the influential accreditation organization has singled out excellent performance on “the best of the best” quality measures, Chassin said. The 405 top performers — which represent about 14 percent of more than 3,000 accredited hospitals that report the relevant data — were not listed in any particular order; they simply made the cut. Some made the list for achieving high scores in one category of care. Others had high marks in all five categories.

“To not be listed in the top 405 hospitals, you can imagine, for Johns Hopkins, was quite startling, and we are absolutely redoubling our efforts to make sure we focus on these things,” said Peter Pronovost, Hopkins’s senior vice president for patient safety and quality.

Most hospitals not on the list are performing reasonably or even very well, Chassin said.

Some other rating systems, he said, rely heavily on a hospital’s reputation or on outcomes, both of which are flawed measurement approaches, he said. A hospital’s reputation may have more to do with research capacity and “brand-new treatment opportunities for patients.”

By contrast, the 22 specific measures identified by the commission are basic “bread-and-butter metrics,” he said. “They are not controversial. Everybody agrees they should be done.”

Those hospitals that did not make the list might be distracted by “more glamorous things, like new technology,” he said.

The Washington Hospital Center did not qualify as a top performer because it missed the required score of 95 percent on three of 22 measures, two of them by less than two percentage points.

“We do flashy stuff, but we also do the bread and butter,” said Janis Orlowski, chief medical officer at the 926-bed center, the largest private hospital in the District.

Executives at some left-out hospitals said patients at larger institutions tend to be sicker than patients at smaller facilities, and those sicker patients could be considered exceptions to certain kinds of treatment, said Greg Meyer, senior vice president for quality and safety at Massachusetts General. For that reason, the hospital might give a patient a non-standard antibiotic or not give a vaccine, he said.

Nevertheless, Meyer said, “we should be doing better, and we’re actively working on these issues.”

Chassin said some larger hospitals may excuse their lower scores by saying that they have to cope with a larger patient load. But those facilities also have more resources. “The fact that you’ve got a lot more patients doesn’t relieve you of the obligation to produce excellence consistently,” he said.

“You don’t have to be a big hospital to do well and, if you’re a big hospital, it doesn’t mean that you’re doing well without paying attention to these very important processes of care.”

The Washington region’s only top performer, Holy Cross Hospital, is a 448-bed facility that is part of Trinity Health, a Catholic hospital system based in Michigan. The hospital, one of the largest in Maryland, had nearly 28,000 admissions in fiscal 2010.

Yancy Phillips, senior vice president for quality and safety, said the hospital’s performance was a reflection of the organization’s commitment to robust processes, rigorous monitoring and accountability of clinical staff.

“The fact that we received recognition . . . shows it’s really hard-wired in the organization,” he said. “It’s hard work. You have to do it every day. We recognize it’s a challenge for us.”

Complex criteria

The commission used a complex methodology to calculate its top performers. Generally, hospitals had to score at least 95 percent on 22 quality measures. The data were based on hospital records for 2010.

Baltimore powerhouse Hopkins scored below 95 percent on five measures. Its lowest scores were in providing appropriate pneumonia care. One protocol calls for admitted pneumonia patients age 65 or older to be given the pneumonia vaccine before discharge, to prevent them from getting pneumonia again. Another measure calls for pneumonia patients who are in the hospital during flu season to receive the flu vaccine.

Only 80 percent of Hopkins’s pneumonia patients received the pneumonia vaccine, and only 75 percent received the flu vaccine.

Pronovost said Hopkins doctors may have chosen not to give the vaccines to sick patients to avoid causing a fever, which sometimes happens, though rarely. If a sick patient got the vaccine and ran a fever, doctors would not know whether the fever was from an infection or from the vaccine, he said.

Other area hospitals also scored below 95 percent in pneumonia care, including Inova Fairfax, Georgetown University Hospital, George Washington University Hospital and Suburban Hospital. Officials from each institution said they are working to improve their performance.

George Washington University Hospital, which fell below 95 percent on nine measures, gave 62 percent of pneumonia patients the pneumonia vaccine before discharge. On four surgical care measures, it missed the 95 percent mark, but often by less than one percentage point.

“We know we provide excellent patient care, but we know there’s always room for improvement,” according to a statement from Gary Little, the hospital’s medical director. Since the 2010 data were released, he said, the hospital has undertaken a number of initiatives, and recent numbers show progress. He did not elaborate.

At Suburban Hospital in Bethesda, which was acquired by Hopkins in 2009, scores were below 95 percent on 11 measures, including several related to pneumonia. The hospital has since changed some procedures. For example, hospital pharmacists are now certified to give the vaccine once nurses identify patients who meet the criteria, spokeswoman Ronna Borenstein-Levy said.

The result has been nearly 100 percent compliance for the first half of 2011, she said.