Core measures include surgical site infection
Joint Commission ponders problem
The thorny issue of post-discharge surveillance for surgical site infections (SSIs) threatens to undermine the accuracy of data reported on SSIs as a core quality measure to the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. The Joint Commission is aware of the problem, but it is not immediately clear how it is going to be corrected so that facilities with the best post-discharge surveillance don’t appear to have the highest infection rates.
Under its ORYX initiative, introduced in 1997 to integrate outcomes and other performance measurements into the accreditation process, the Joint Commission is moving to a continuous data-driven accreditation process. The ORYX initiative was designed to be implemented in phases, with the use of nationally standardized core performance measures as a planned component. As approved by the Joint Commission and its advisory panels in February, 25 core measures are planned under the following five areas: acute myocardial infarction, heart failure, pneumonia, pregnancy and related conditions, and surgical procedures and complications. The fifth category includes SSIs within 30 days of the procedure and timing of antibiotic prophylaxis prior to surgery. (See box, p. 59.) Acute care hospitals that serve patient populations whose conditions correspond to two or more of the core measure areas will be required to choose two measure sets from among the initial five by Sept. 1, 2001, according to the Joint Commission.
But difficult questions about the method and intensity of post-discharge surveillance used by hospitals tracking SSIs need to be resolved if the core measures are to be accurate and effective, says Bryan Simmons, MD, a member of the Joint Commission advisory committee on the SSI core measure.
"[The committee] talked about surveillance intensity, that hospitals that do a worse job at surveillance will actually look better than hospitals that do a better job, particularly with post-discharge surveillance. But it was felt that we could not mandate that," he says. The panel reached an impasse when discussion turned to the resources needed and the unresolved issues of what type of post-discharge surveillance should be required (i.e., send cards or phone patients, contact surgeon, etc.). "[Committee discussions indicated] that this would be time-consuming and costly and still would not be exactly comparable because there is no one method of post-discharge surveillance that the [Centers for Disease Control] or anybody else has recommended," Simmons says.
As a result, the advisory committee did not recommend a post-discharge surveillance component to the Joint Commission as part of the SSI core measure, though Simmons warned that those with the best surveillance programs could fall victim to misperceptions. "It was elected not to do this, but with full knowledge — at least by me, and I expressed this to the others there — that this may result in the hospitals doing the best job of post-discharge surveillance looking the worst," he says. "The data look like 30% to 70% of infections that occur after surgical procedures are first detected after discharge from the hospital. So [even] if it’s only 30%, your rate will look 30% worse, everything else being equal."
The Joint Commission is aware of the problem and likely will take action to correct it as the SSI core measure specifications are finalized, says Jerod M. Loeb, PhD, vice president for research and performance measurement at the Joint Com-mission. "In view of the short lengths of stay today, I think of necessity it is almost without doubt that [the SSI core measure] is going to include some form of post-discharge surveillance," he says. "At this juncture, the specifics of that form of post-discharge surveillance — i.e., phone call, card, letter, or whatever — is unclear. All of [that] will be clarified as the measures have their specifications developed."
(Editor’s note: Copies of the Joint Commission’s core measures and related documents can be found on the Web at www.jcaho.org/permeas/coremeas/cm_ pub.html.)
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