Is ORYX a QI boon or burden?

Joint Commission aiming for standardization

You’ve heard by now: Accredited hospitals will be required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, to submit data on two performance indicators — or outcomes — by the end of March 1999. The initiative is called ORYX, named after an African gazelle.

Is this new outcomes reporting requirement going to improve the quality of our nation’s health care or simply add to hospitals’ administrative and financial burdens?

The Joint Commission claims the data will be useful in helping health care organizations:

• strengthen their efforts to identify issues that require attention;

• verify the effectiveness of corrective action;

• compare their performance to peer organizations.

It also could lead to more standardization in outcomes reporting, making possible more meaningful comparisons between hospitals and reporting systems.

"There’s a clear expectation of a demonstration of improvement," says Dennis O’Leary, MD, president of the Joint Commission. "We’ve raised the crossbar. We’ll be looking at trend lines, and when we see one going in the wrong direction, we’ll ask for a written analysis of the problem. Ultimately, we’ll send out a team to investigate." The Joint Commission will expect evidence of improvement within six to 12 months of data collection.

Most everyone agrees performance measurement is essential to quality improvement, but opinions vary as to the initiative’s efficacy. Some QI personnel don’t see the necessity of creating the additional labor and mechanisms for reporting to the Joint Commission unless it results in some real gains.

What is JCAHO’s intent?

The question comes down to the actual intent of the Joint Commission, which some have accused of creating ORYX as a money-making initiative. If the intent is purely regulatory — to ensure that hospitals are monitoring indicators — most have concerns that ORYX will create unnecessary work.

Apparently the Joint Commission doesn’t even put much stock in the program’s initial requirement: that hospitals choose a JCAHO-approved performance measurement system and select two outcomes that affect at least 20% of patients by December 31, then begin submitting data on those two outcomes by March 31, 1999.

"We fully expect that the first two indicators hospitals choose will be ones that make a favorable impression. But the requirement levels will go up over time, so within a few years it won’t be so easy to identify such positive indicators. Our first priority is to get everyone on the train, then to improve the process," O’Leary says.

"How is the ORYX initiative actually going to improve patient care?" asks Patrice Spath, ART, a consultant in health care quality and resource management in Forest Grove, OR. "In this environment of cost containment, we can’t afford to spend dollars on things that are meaningless. I’m all in favor of individual providers having comparative benchmarking data to evaluate their performance. At the local level, that data has a real impact on patient care improvement. But how will sending that data to the Joint Commission improve patient care quality? Will ORYX prevent sentinel events? Most sentinel events occur in low-volume patients. By definition, that population wouldn’t be a part of one of our indicators for the Joint Commission."

Comparing apples to oranges?

With 60 approved vendors, can the Joint Commission standardize specific indicators nationally so everyone can compare apples to apples?

"I’m happy the Joint Commission is making an effort to coordinate us," says Karen Reeves, RN, vice president of professional services for the South Carolina Hospital Association in Columbia. Reeves’ organization runs the South Carolina Quality Indicator Project, a reporting system that the Joint Commission has approved.

Fortunately, in the early stages of ORYX, hospitals will be compared only to others using the same system. That will change down the road, though.

"If the Joint Commission takes measures from, for example, the Maryland Quality Indicator Project and bundles them with measures from another project, the outcomes will be unreliable data because different projects maintain different data definitions," Spath says.

The performance measurement systems and the Joint Commission will conduct periodic data quality audits to minimize anticipated problems, O’Leary says. In addition, ORYX PLUS, a system for hospitals engaged in performance measurement activities at levels well beyond the basic ORYX requirement, involves the use of a common set of acute care measures, all of which have been tested for reliability, validity, and discrimination capability.

With the requirement that data be reported quarterly, ORYX is a move toward continuous monitoring of accreditation status that could trigger an interim survey any time the submitted data don’t pass muster. If you don’t comply with ORYX and provide timely outcomes information, your facility will automatically receive a special Type I recommendation. Left uncorrected, the blemish on your record could lead to conditional status and ultimate loss of accreditation.

Fortunately, most hospitals have little to fear from the first stage of the new requirements, which do little more than ask for information that facilities are likely to have already.

Even though you’re probably already measuring outcomes, ORYX still will subtract from the bottom line, QI professionals agree. "The Joint Commission is saying, in effect, ‘Every three years we come and survey you and charge $10,000 for that, and now we want you to spend nearly $100,000 to join a performance measurement system,’" Spath says.

The Joint Commission estimates the start-up cost at about $10,000, not including the hidden costs of adopting a new system — hiring new personnel or training current staff, for example. Ongoing maintenance costs should be about $11,000 annually.

"Costs go beyond buying hardware and software," Spath says. "Running [the systems] is resource-intensive. Someone has to collect and format and submit the data. This could result in a significant economic burden on hospitals."