TJC readies new performance standard

Standard puts teeth behind reporting requirement

Most accredited hospitals have been reporting ORYX performance data to The Joint Commission (TJC) on a monthly basis since 2002. But beginning on Jan. 1, 2012, TJC is putting teeth behind these measures, requiring an 85% compliance rate on a single composite rate, reflecting all accountability measures, in order to meet accreditation standards.

"This is really the first time The Joint Commission will be implementing a standard directly addressing performance on the reported measures," says Stephen Schmaltz, PhD, TJC's associate director in the Center for Data Management and Analysis, Division for Healthcare Quality Evaluation. The new standard does not apply to critical access hospitals.

Schmaltz emphasizes that how individual hospitals are performing on these measures should not come as any surprise because the JC has been providing regular feedback on their ORYX performance data and how they compare against other hospitals nationally. Further, at the end of this year, TJC will begin providing to hospitals the overall composite measure that they will be judged by, so they will see it before the standard goes into effect, Schmaltz says.

The composite rate will be calculated using the most recent four quarters of data that are available at the time a hospital is surveyed. "For most organizations we will be looking at the third and fourth quarters of 2010 and the first and second quarters of 2011," says Sharon Sprenger, RHIA, CPHQ, MPA, senior advisor, Measurement Outreach, Division of Quality Measurement and Research. "But keep in mind that it will be a rolling four quarters going forward, so it may vary a little bit from hospital to hospital depending on when they are surveyed."

The composite measure is derived by taking the sum of all numerator counts of a hospital's accountability measures from all measure sets, and dividing that by the sum of all the denominator counts from the same accountability measures.

The current accountability measures pertain to care that is provided to patients that have experienced heart attacks, heart failure, and pneumonia. In addition, there are measures related to surgical care and to the care of children with asthma. "We believe that these are the measures that have the greatest positive impact on patient outcomes when hospitals demonstrate improvement," Sprenger says. "We have come to realize that only certain measures should be used for purposes of public reporting, accreditation, and pay for performance."

Sprenger notes that TJC selected these measures based on four criteria, including:

  • strong scientific evidence that compliance results in improved outcomes;
  • a close linkage between the process and an outcome;
  • ability to accurately assess or measure the process of care;
  • the process of care is associated with minimal unintended adverse effects.

In 2010, The Joint Commission began to comb through its data to determine which measures met the threshold for being accountability measures, says Sprenger, noting that the accrediting agency began with four measure sets that it has in common with the Centers for Medicare & Medicaid Services (CMS) and one measure set that TJC collects that CMS posts on its Hospital Compare website. "We identified or reviewed 28 measures, 22 of which we felt met the accountability criteria," she says. "Then we identified six measures we labeled as non-accountability measures, which we believe are more suitable for secondary uses."

The non-accountability measures include providing smoking cessation advice to patients with heart attacks, heart failure, and pneumonia; providing antibiotics to patients with pneumonia within six hours of arrival to the hospital; and providing discharge instructions and LVS function assessments to patients with heart failure.

The Joint Commission fully intends to add more accountability measures to the mix soon, but these data points will be collected for 12 months before they are calculated in the composite measure. The agency also intends to gradually inch up the compliance standard for accreditation. "We anticipate moving that up to a 90% threshold eventually," says Schmaltz. In 2010, TJC reports that 98% of hospitals met an 80% compliance rate and 92% met a 90% compliance rate.

As of Jan. 1, 2012, hospitals that fail to meet the 85% compliance rate for the accountability measures at the time of their survey will receive a requirement for improvement (RFI) in their accreditation report, and they will have an opportunity to address the problem, says Sprenger. To assist these organizations and any accredited hospitals that are striving to improve their performance on these measures, TJC launched a "Core Measures Solutions Exchange," an online tool that enables hospitals to share their success stories and offer up strategies that have proven to be effective.

"We are really trying to facilitate dialogue between hospitals so that they can help each other learn," says Sprenger. "They can search for solutions, post comments, rate the usefulness [of a strategy], and note if they think a particular solution is transferable to another organization."

The solutions can be searched by measure so if a hospital is having difficulty with a particular measure, administrators can pull up that measure to see what organizations have done to improve their performance in this area, adds Schmaltz. The online exchange is only available to accredited organizations to review.