JCAHO wields double-edged sword: Standards intact, but show us the data
ORYX: Some wondering if this gazelle looks more like an albatross
The Joint Commission on Accreditation of Healthcare Organizations is not retreating from its historic commitment to infection control standards, but it still is largely up to individual ICPs to underscore their roles and protect their own turf in the ongoing restructuring of health systems, a commission official tells Hospital Infection Control.
The question has arisen in part due to the widespread perception in the infection control community that any weakening of Joint Commission accreditation requirements in an era of reduced census, facility consolidation, and downsizing could spell a loss of jobs for ICPs. (See related story, p. 140.) Nonetheless, the 1997 Joint Commission standards still call for hospitals to have a qualified person managing a program to reduce the risks of nosocomial infections in patients and health care workers.1 The standards cite certification in infection control (CIC) as an example of fulfilling the qualifications aspect, and include a chart outlining the critical aspects of a program to detect and prevent infections. (See standards and chart, pp. 131-132.) There are no plans to de-emphasize the role of infection control; if anything, the Joint Commission has some projects under way that may bolster perceptions of the field in health care, says Carole Patterson, RN, MN, deputy director of standards at the Joint Commission in Oakbrook Terrace, IL.
"It’s up to the infection control practitioner to make that point known when somebody starts thinking we are not serious about infection control anymore," she says. "That is the craziest thing ever. Everybody looks to the Joint Commission to help them protect their turf, but that is not what we are in business for. We are in business to improve the quality of patient care, so we write our standards to focus on the quality things that have to happen in an organization for good patient outcomes. The [ICPs] need to get in there and say, This is what I can do.’"
Long-term interest in infection control is evidenced by the fact that the profession is already earmarked for inclusion in a standards database being compiled by the Joint Commission, Patterson says.
"The fact that we are constructing a database that has a space in it for infection control standards ought to give [ICPs] a great deal of reassurance, because you don’t build databases and then throw something away," she says. "It is in our 10-year strategic plan for managing the 12 sets of standards. Infection control is one of those 12."
In addition, Patterson says the Joint Commission is moving toward a process of "continuous accreditation" that will include reporting quality indicators on an ongoing basis.
"[Infection control] has not diminished in any respect, and in fact, in my view at least, we are increasing it by this concept of ongoing monitoring of health care organizations and the concept of continuous accreditation," she says.
The ORYX initiative
But that ambitious program, which has been dubbed ORYX (after a breed of gazelle), is proving controversial in its own right. There are questions about the validity of the data generated, how it will affect surveillance, and whether it will eventually be publicly disclosed.
According to the ORYX plans launched early this year, by next Dec. 31 each accredited hospital and long-term care organization in the U.S. must select (or already be participating in) one or more performance measurement systems that have been approved by the Joint Commission. There are currently 62 such systems, but that number is projected to increase as more are approved by the commission. Initial requirements call for institutions to select two clinical measures that cover at least 20% of their patient population. The number of measures and the percentage of patients covered will increase as the project is phased in over the next few years. After the selection process is over, facilities are to begin submitting data to the performance measurement vendors by the first quarter of 1999. The vendors will then report findings to the Joint Commission.
Some of the approved systems include infection control data, and others do not. The Joint Commission is leaving it up to individual facilities to decide which system to chose. A question-and-answer document posted by the Joint Commission on its World Wide Web home page cites infection control as one example of fulfilling the initial requirements. (See related story, p. 133.)
The Centers for Disease Control and Preven tion’s National Nosocomial Infection Surveillance (NNIS) system of sentinel hospitals is currently not included among the performance measurement systems, but NNIS may be added if confidentiality concerns can be addressed. Public health law requires that the identities of NNIS hospitals remain confidential, and the CDC’s legal advisors are currently reviewing options for CDC participation, according to a recent editorial on the issue by Robert Gaynes, MD, director of the CDC NNIS system.2 The editorial also raised a concern that has been noted by ICPs: Will ORYX requirements translate to administrative pressure to "under-report" infections because the data may raise a red flag in the eyes of an accrediting agency?
"While the ORYX initiative currently does not provide for public access of data, pressure nonetheless may exist to under-report adverse events because the Joint Commission is, effectively, the regulator of hospitals," Gaynes wrote. "Validation of data is difficult and time-consuming, but will be essential if data from performance-measurement systems are to be credible."
Patterson is confident the Joint Commission will be able to audit and confirm data, noting, for example, that under-reported infections may create a suspicious increase in lengths of stay.
"There are other ways to find that information," she says. "And we’ll be doing spot checks, random show-us-your-data auditing processes."
"The Joint Commission is pretty tuned into the issue that good surveillance means finding more infections," said Deborah Nadzam, FAAN, RN, PhD, vice president for performance measurement at the Joint Commission, when asked to address the issue at the recent conference of the Association of Professionals in Infection Control and Epidemiology (APIC). Regardless, the Joint Commission’s primary concern is still how health care agencies act on their data to improve patient outcomes not numbers for their own sake, she said. She also addressed the issue of public disclosure of the data, saying only hospitals that voluntarily elect to participate in the advanced ORYX PLUS component of the program must agree to disclosure.
"[ORYX PLUS] will require the use of a common measurement set and a commitment to public disclosure of the data by the Joint Commission once we have enough to do it in a statistically meaningful fashion," Nadzam told APIC attendees.
There are no immediate plans to change the triennial on-site accreditation survey process, but in the long run the establishment of a data-driven continuous accreditation process will move the Joint Commission from a "snapshot" evaluation every three years to a review process more akin to a video camera, Nadzam said at APIC. The Joint Commission originally planned to develop a single performance measurement system for all facilities, the Indicator Measurement System (IMS). The IMS, which includes infection control measures for ventilator-associated pneumonia and bloodstream infections, is still in operation, but now is only one of the many approved systems from which hospitals can choose, Nadzam explained. Nonetheless, ORYX’s acceptance of so many performance measurement systems has opened the Joint Commission to criticism that it has gone from "apples-to-apples" comparisons to something akin to a fruit punch.
"To me, it’s putting apples, oranges, and bananas together and putting it in a blender," William Jarvis, MD, acting director of the CDC hospital infections program, told APIC attendees. "We need to continue working with [the Joint Commission] to help them understand that a lot of the data they are collecting is garbage-in/ garbage-out. And if they start putting together garbage with the non-garbage it is going to be meaningless. . . . It is a very complicated process that is going to require a lot of input from the hospital epidemiology and infection control community if we are going to come out the other end with something valuable."
In addition, because the ORYX plan calls for a gradual increase in both the number of indicators and the patient population covered, some question whether infection control data will be a major component of the system in the long term. For example, as the percentages of patients covered increases, infection rate data may account for a smaller piece of the pie because many ICPs will drop broad surveillance approaches in favor of targeted programs aimed at smaller, high-risk populations. On the other hand, some of the performance measurement systems may call for collection of infection rate data that ICPs may consider useless for their program, making it paramount that they get involved in the criteria selection process, emphasizes Marguerite Jackson, RN, PhD, CIC, FAAN, administrative director of the medical center epidemiology unit at the University of California in San Diego. Jackson is on a subcommittee at her facility that is reviewing the situation and will make a recommendation to administration regarding ORYX.
"I would say in most cases the infection control professional is not part of that decision-making group," Jackson says. "ICPs better find out what is going on with ORYX and get themselves in the loop."
[Editors’ note: For more information on ORYX, consult the Joint Commission’s Web site at http:// www.jcaho.org, or call the ORYX information line at (630) 792-5085.]
References
1. The Joint Commission on Accreditation of Healthcare Organizations. 1997 Accreditation Manual for Hospitals. Oakbrook Terrace, IL; 1996.
2. Gaynes RP. Surveillance of nosocomial infections: A fundamental ingredient for quality. Infect Control Hosp Epidemiol 1997; 18:475-478.
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