ORYX data to play key role in new JCAHO survey process

New process doesn’t mean greater data collection burden

With the advent of "Shared Visions — New Pathways," a great many things about the Joint Commission’s survey process will change in 2004, but the collection of ORYX data isn’t necessarily one of them, says Jarod M. Loeb, PhD, vice president of research and performance measurement with the Joint Commission on Accreditation of Healthcare Organizations. Health care providers already are required to collect ORYX data, and by 2004, they will be transmitting the data to the Joint Commission.

"Shared Visions — New Pathways will not mean the hospital is going to incur any new burden in terms of collecting data," Loeb says. "They already have data if they’re reporting sentinel events, or if there have been previous recommendations for improvement, and they will have data in 2004 from the core measures. So from the hospital’s perspective, other than the fact that they will be doing a self-assessment, they’re already going through these data collection in some way."

When the "Shared Visions — New Pathways" process was being developed, a key concern was that health care providers not be saddled with even more requirements for data collection or other burdens. Loeb says ORYX data will be key to helping the Joint Commission focus surveyors on the most important topics and to create more consistent performance from surveyors, but the hospitals won’t notice a difference in how they provide ORYX data.

"This is a situation in which we really think the value will be enhanced without organizations having to do anything more, other than the self-assessment, to participate in the survey process in 2004," he says. "Any organization that is currently involved with the collection of data will see absolutely no new requirements with the new survey process."

Accredited hospitals began collecting core measure data in July 2002. Hospitals were allowed to choose from four core measurement areas. As of Oct. 29, the Joint Commission reports, 2,100 hospitals chose heart failure; 2,000 chose community-acquired pneumonia; 1,600 chose acute myocardial infarction; and 950 chose pregnancy and related conditions.

The four options were offered because they are useful for the ORYX initiative and also for facilitating an individual hospital’s organizational process improvement. A hospital can choose the core measure set based on the services it provides, and surveyors will assess a hospital’s use of its selected core measure sets in its performance improvement activities during the on-site survey process. Eventually, the Joint Commission will use core measure data for focusing on-site survey evaluation activities.

Long-term care, home care, and behavioral health care organizations can put off the whole question for a while. The Joint Commission announced recently that those organizations will be permitted to defer the reporting of data from their ORYX measures until applicable core measures are identified. "However, these organizations will continue to be expected to meet standards-based requirements for performance measurement, and to present relevant performance data and actions taken in response to these data during the Joint Commission’s on-site surveys," according to the accrediting body.

The announcement doesn’t mean you can’t report ORYX data if you want. Accredited long-term care, home care, and behavioral health care organizations that wish to continue to report measurement data to the Joint Commission may continue to do so.

In addition, the Joint Commission is developing and will offer an extranet option beginning in mid-2003 that will permit accredited long-term care and home care organizations to use the same data to satisfy both federal performance reporting requirements and ORYX requirements.

This option is expected to appeal to the approximately 93% of accredited long-term care organizations and 60% of accredited home health agencies that are already required to gather and report Minimum Data Set (long-term care) and Outcome and Assessment Information Set (OASIS) data (home health care).

The modified ORYX refinements "acknowledge the slow pace at which national consensus is being reached on appropriate performance measures for nonhospital settings of care," the Joint Commission says. The modifications also will eliminate what some organizations have seen as duplicative federal and private accrediting body requirements.

The Joint Commission plans to continue to work with the Centers for Medicare & Medicaid Services, the National Quality Forum, and other stakeholders in the long-term care, home care, and behavioral health care fields to identify appropriate core measure sets.

Once suitable core measures have been identified for organizations in any or all of the three accreditation programs, the Joint Commission will require accredited organizations to transmit core measure data to the Joint Commission via its extranet site or through a JCAHO-listed performance measurement system.

The Joint Commission reports that core measures will be identified for the long-term care field by mid-2003. A timeline for final development of core measures for the other two fields is "highly speculative," the Joint Commission reports.

[For more information, contact:

  • Jarod M. Loeb, PhD, Vice President, Research and Performance Measurement, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000.]