Hospitals threaten to pull plug on ORYX, demand more say in JCAHO decisions
Hospital associations, AHA file protest; JCAHO scrambles to respond
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, is scrambling to appease hundreds of hospitals that have effectively called a halt to their participation in ORYX, JCAHO’s new electronic reporting system, until the commission addresses their objections and provides an avenue for input from providers.
In early January, 17 state hospital associations sent a letter of complaint — accompanied by a supportive letter from the Chicago-based American Hospital Association (AHA) — to the JCAHO, protesting the Joint Commission’s newest effort to electronically collect performance and outcomes data. The hospitals said ORYX doesn’t make sense, won’t work due to a lack of uniformity in the various reporting software, and is too costly.
Hospitals: Is ORYX even necessary?
They say they are fed up with a regulatory commission in which "the right hand doesn’t know what the left hand is doing,"and is seemingly insensitive to the burden and expense its year-old reporting program and new core standards program are heaping on the hospitals.
They are calling for more provider input and frankly questioning the need for ORYX in light of existing reporting programs and requirements. They further complain that the Joint Commission has yet to demonstrate it can hold up its end of the program because it has failed to process data and provide feedback in a timely manner.
JCAHO president Dennis S. O’Leary, MD, quickly called for meetings with the hospital associations to discuss the issues raised in the letter. For now, the state associations are diplomatically saying they expect the Joint Commission to respond positively to their concerns. O’Leary was unavailable to be interviewed by Hospital Peer Review.
The AHA letter, written by Don M. Nielsen, MD, senior vice president for quality leadership, assured O’Leary that the AHA supports the concerns of the 17 signatories and said that in the past year, "there was immense difficulty in the implementation of the sentinel event policy and the restraint standards policy and the untested implementation of the present ORYX policy."
The concerns in the associations’ letter center on the recent efforts by the Joint Commission to fold into ORYX a core set of performance measures that are related to focus areas previously defined by the Advisory Council on Performance Measurement. (See box on p. 47 for a list of the Advisory Council’s 12 focus areas.)
The letter singled out these six issues, summarized below:
1. Hospitals and health systems around the country have made a good effort to comply with the original ORYX performance measurement policy, even though that policy was developed by the Joint Commission with minimal input from those who were to be affected by its implementation. And those efforts to comply were expensive. "Now, a second measurement effort is to be developed with little to no input from those affected that will incur significant additional expense without any demonstrated effectiveness relative to the first policy."
The initial documents describing the core measurement effort are confusing and use terms referencing "assigned" and "selected" interchangeably. They lack clarity regarding phase-in of new core measures and phase-out of present ORYX data requirements. Effectuation is flawed, causing difficulty with implementation and "generating much animosity toward the JCAHO." Before proceeding with further development, "serious thought should be given to seeking and listening to informed input and involvement from those institutions and systems that are to be affected by this second measurement policy."
Not everyone at JCAHO agreed, either
2. This could be stated as "the left hand doesn’t seem to know what the right hand is doing." The proposed core measurement policy appears not to have been fully discussed by the Joint Commission’s Board of Commissioners or the Advisory Council of Performance Measurement. Two members of the council are cited who confirmed lack of approval. "Full understanding of the operational issues and support from each of these entities should be present before proceeding with implementation."
3. Transmission of data to approved vendors and from the vendors to the Joint Commission doesn’t seem to be occurring effectively. "The JCAHO’s capability to collect and evaluate the data from all institutions has yet to be demonstrated." Implementation of a second measurement effort that will superimpose additional data collection and evaluation requirements should not occur until those inadequacies have been corrected.
4. The proposed time line creates operational problems for facilities. "If the transition is made from the current ORYX initiative to the core measures program, the proposed one year increase in the number of measures from a minimum of 8-17 results in more than a 100% increase in staff time and resources." Also, the continuation of current ORYX requirements past a minimum of six measures does not result in any benefit for the organization — no time is provided to organizations to develop and implement quality improvement efforts in response to their performance measurement activities. It is recommended that a cap be placed on the current initiative in 1999 when six to 10 indicators are reached so efforts can focus on improving performance.
5. Multiple entities, including states and managed care plans, require measurement efforts. "Any new measurement effort should evaluate existing and proposed future data collection requirements prior to embarking on the development of an additional measurement set" and should represent an effort to prevent duplicative, overly burdensome requirements.
6. How many vendors are going to go to the expense of adding the proposed core measures vs. dropping their participation in the program? Facilities ultimately will have to pay the costs incurred by the vendors when they add measures.
The associations’ letter closed with the request that the Joint Commission reconsider its approach. The associations asked that "an active dialogue begin" between accredited institutions and the Council of Performance Measurement and the Board of Commissioners. "We firmly support the concept of performance measurement and accountability for improvement," stated the letter.
O’Leary responded immediately to the letter, stating that the Joint Commission is committed to meaningful dialogue with organizations and their associations at multiple stages throughout the process for identifying core measures. He said that intent was articulated at the October Board of Commissioners meeting, and a more specific outreach plan regarding the core measures project would be considered at a meeting of the Executive Committee later in January.
His letter said the letter from the 17 associations raised some significant issues, but also contained some misperceptions. O’Leary wrote that he wanted to correct that situation, so he’s arranging to facilitate an open forum between the state hospital associations and the Joint Commission. The forum would include all state hospital associations, not just the 17 signatories.
"I do finally wish to challenge the assertions set forth in item 2," stated O’Leary’s letter. "The awareness of, and support for, the core measures project by the Advisory Council on Performance Measurement and the Board of Commissioners is a matter of record." Both had reviewed and supported the Framework for Determining Core Measurement Priorities, the Attributes and Criteria to Guide the Selection of Core Performance Measures, and the specific priority areas for core measure identification for hospitals, he wrote. Also, at the October meeting, the Board discussed a plan for shifting to core measures from current ORYX requirements. "It was agreed that appropriate timelines for core measure implementation would be determined when there was a reasonable experiential base for doing so."
O’Leary wrote that the state hospital association’s letter provided an opportunity for crystallizing key policy issues surrounding the eventual introduction of core measures into the accreditation process.
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