ED Accreditation Update: More core performance data required in 2004

Measures for MI among those needing ED data

As of Jan. 1, your accredited hospital was required to collect and report data on one additional core measure set as part of an expansion of the Joint Commission on Accreditation of Healthcare Organization's ORYX initiative.

Emergency departments are unlikely to notice dramatic change in terms of time spent collecting data, some ED managers say.

"We don’t actually do that [collect data] ourselves; our QI [quality improvement] department does," says Rich Lowery, director of emergency services at Euclid Hospital, Euclid, OH. And the ED at Good Samaritan Hospital in Dayton, OH, benefits from a computer tracking system that gathers core performance data, says Barbette Spitler, RN, nurse manager. But both say any time new data is required from the ED, there is some increase in demand on ED staff.

But the Joint Commission is studying new core measures that would involve ED participation in collecting data — such as for pediatric asthma, expected to be introduced in 2005 — and even core measures that specifically focus on the ED, according to Sharon L. Sprenger, RHIA, CPHQ, MPA, project director for the Joint Commission's Division of Research.

"This year, the only new core measure being introduced will be on surgical infection control, and that will have no impact at all on the ED," she adds. But ones on the horizon — pediatric asthma and pain management, for example — likely will draw on EDs for data.

The Joint Commission estimates that hospitals spend anywhere from 12 to 15 work hours per month, total, per set of measures.

The ORYX initiative was introduced as a pilot program in 1999 as a means of collecting data on standardized, or core, performance measures.

Core measures compare a hospital's performance against national quality goals and Joint Commission core measures. In July 2002, accredited hospitals began reporting data in four areas identified by the Joint Commission: acute myocardial infarction, heart failure, community-acquired pneumonia, and pregnancy and related conditions.

Each core measure set has from four to nine components aimed at documenting arrival, treatment, length of stay, and discharge/mortality.

Before Jan. 1, 2004, most hospitals were required to report data on two of those four core measure sets (which two depended upon the health care services the hospital provides), but now are required to report on a third.

Four new core measure sets are being developed and are expected to be introduced during the next two to three years.

Starting this year, core measure data are being used by the Joint Commission in focusing on-site survey evaluation activities. Data will be posted on the Joint Commission web site (www.jcaho.org) in late 2004.