Joint Commission Q&A on ORYX program
(Editor’s note: The Joint Commission on Accreditation of Healthcare Organizations has posted a question-and-answer briefing on its new ORYX initiative on its Internet site at http://www.jcaho.org. Key excerpts are summarized below.)
What are the staffing and cost implications of the ORYX requirements for accredited organizations?
A field survey conducted by the Joint Commission in August 1996 indicated that nearly 70% of hospitals are already participating in a performance measurement system. Most respondents indicated that they spend less than $11,000 annually to maintain their system participation and utilize 1.5 full-time equivalents (FTEs) or fewer to operate the system. A survey of long-term care organizations indicated approximately one-third of the facilities currently participate in a measurement system. Respondents indicated that they pay less than $11,000 annually in related fees and expenses. On average, the facilities reported that 2.5 FTEs are required to operate the system. While there is no specific basis for challenging these data, we believe these expense estimates may be somewhat understated.
How did the Joint Commission determine the requirement for selecting at least two clinical performance measures that relate to at least 20% of the organization’s patient or resident population?
Results of the August 1996 field survey indicated that the majority of hospitals and long-term care organizations are using between 10 and 24 measures. The decision to require only two clinical measures as long as they address at least 20% of the organization’s patients or residents is intended to be minimal to reduce or eliminate any real or perceived barriers for organizations in meeting the new requirements. For many hospitals, a single broad surgical measure, an obstetrical measure, or a cardiovascular measure would probably address more than 20% of patients. An infection control or medication usage measure might also meet this modest requirement.
What happens if an organization chooses not to enroll in a performance measurement system and provide performance data to the Joint Commission?
Failure to meet the new performance measurement requirements will lead to a special Type I recommendation. The organization will have one month to provide a written progress report explaining its plan of correction. Extended failure to meet the new accreditation participation requirements could lead to loss of accreditation.
What can an organization do if its measurement system is not on the current list of contracted measurement systems?
The organization should urge its measurement system to contact the Joint Commission’s Department of Research and Evaluation to obtain an application for consideration by the Council on Performance Measurement for inclusion on the list of acceptable measurement systems. The Council will consider new applicant systems twice a year.
How will the Joint Commission use disparate measures from disparate systems to make comparable judgments about organization performance?
The health care organization’s performance data will be compared only to its own data over time and to the data from other health care organizations that have selected the same measures in the same system. As with the use of data in all other situations, the data will be used to raise questions about, not judge, organization performance.
How will the data affect an organization’s accreditation status?
The accreditation decision will continue to be standards-based. However, patterns or trends in the submitted data may signal noncompliance with certain Joint Commission standards. If noncompliance with standards is confirmed by a survey, the scoring of the relevant standards may affect the organization’s accreditation status, just as is currently true.
How will the Joint Commission use the data submitted by the health care organizations?
The Joint Commission will monitor the data for significant patterns and trends. When significant variances in the data are identified, a staff member will contact the accredited organization to either alert the organization to the variance or determine what action the organization has taken to respond to the variance. The Joint Commission’s primary interest is in how the organization uses the data to improve, and ultimately, in the results of the improvement activity. If the data suggest standards compliance problems in specific functional areas, a written progress report or on-site survey may be required.
Will performance measurement data be made public?
Given the large number of participating measurement systems and the degree of variation expected in the measures selected, public disclosure of the data reported would not be helpful to the public. Therefore, there are no plans to disclose these data. However, as common measures are identified across participating systems, this potential will be reconsidered. Along these lines, ORYX PLUS hospitals will be expected to authorize disclosure of their data.
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