TJC looking for core measure 'accountability'

Final change slated for 2012

In October 2010, The Joint Commission told Hospital Peer Review it was going to change the way core, or ORYX, measure data was used to accredit hospitals. While historically hospitals have had to merely report data, TJC began looking at ways to measure the "quality" and hold hospitals more "accountable" to yielding improved outcomes.

At press time, The Joint Commission had issued "a proposed requirement to establish performance targets for compliance with ORYX accountability measures." Comments are due Feb. 22 at

"Organizations have been submitting ORYX measures for eight years, but we've never really had any specific requirements about having to perform at a certain level. So, we're figuring that now might not be such a bad time to introduce those kinds of requirements," says The Joint Commission's Maureen Carr, MBA, project director, standards and survey methods, division of health care quality evaluation.

"What we're proposing is an element of performance that would be added — we haven't identified specifically where — but would be added to the standards that actually set a performance target for the ORYX measures, and we would be using a composite number across all measures," she says.

There were a number of ways the organization could have chosen to measure accountability, she says. But in the proposed requirement, it chose to go with only one composite measure. "At the beginning, we think that would probably be the best way to do that for now," Carr says.

The single measure takes the sum of all the numerator counts across all measure sets and divides it by the sum of all the denominator counts from across all accountability measures. "Another way that one could have done that would be to, for example, look at it by measure — scores by measure or by measure set — and that would be a bit more complex. So, it was felt that this would be the most inclusive for all hospitals, and this does only apply to hospitals at the current time. And it was just felt that this was the simplest way to do it," Carr says.

The final change is expected to be in place in January 2012 and would be applicable for hospital settings, not for critical access hospitals. Final information about the requirement will be out by July 1, 2011.

"There's downsides, obviously, that some things that you're performing very well on could mask something that you're performing very poorly on, and we understand that. But, nevertheless, you still have your individual performance at the individual measure level so you can tell where you're not performing well," she says.

If hospitals do not meet the aggregate number, regardless of which measures are reported on, they would receive a request for improvement, or RFI. Carr says it won't come as a surprise to hospitals because the composite number will be included as part of your ORYX report. "The idea would be that, once you're scheduled for survey — and, of course, we're always unannounced, but we know inside here when people are scheduled, obviously"— that TJC would pull ORYX data from the last available four quarters.

She says the next steps also are up in the air at this point. "There is one thought that we could ask organizations to submit a plan of correction indicating how they're going to improve their performance on the measures. And that would be due, like in the normal time frame of an RFI, 45 or 60 days. And then we would expect to see actual improvement in a certain time frame. And that's, again, another thing that's under discussion in this field review. How much time will organizations need to demonstrate compliance, recognizing that the data submissions are old. So, when they're surveyed, they've already submitted data," she says.

Asked whether that plan of correction would be specific to a measure set, she says that also has not be established but it could be that a hospital would have to identify which areas it could improve to meet the composite score.

"I think what we're really trying to do is establish — at least in this initial phase — some level of performance that we'd like people to be at. Recognizing that...most organizations are doing pretty well. So, there's not going to be a whole lot that are going to have a problem here based on that data. So, we're trying to be not unrealistic, we're not trying to mess people up. But we do want to set some expectations," she says.

She says the core measures lend themselves more to establishing a target and building a level of accountability that hospitals must meet because they are evidence-based, researched, and specific. Asked if TJC will look toward establishing a similar approach across the board, Carr says, "standards have a certain role. They're not the same as measures. They more often talk about processes and things that need to occur within an organization. They tend to be more general than measures, talking about processes of providing care [such as] processes for preventing infections, processes for safe medication management, and they don't usually get down into the detailed, specific level that a measure does," she says.

"A lot of times for standards, on these issues of processes, you don't have that same kind of research that exists at all. So, you can't just say that we're going to have all the same evidence for standards because it doesn't necessarily exist. People haven't done double-blind studies on whether or not you should do a history and physical. But that's the consensus in the field, that that kind of information is important. So, I think we have to be a little bit cautious about just saying that everything's going to be based on the same kinds of evidence," she says.