ORYX is right around the corner; is your department ready?

New performance measures could strain case management resources

The Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is touting its new ORYX initiative as "the next evolution in accreditation." But it could be your case management department that feels the growing pains, experts say.

ORYX represents the Joint Commission’s first stab at integrating performance measures into the accreditation process. To comply with the initiative, hospitals must select a JCAHO-approved performance measurement system and at least two clinical performance indicators by Dec. 31 or receive a special Type I citation. By March 31, 1999, hospitals will be required to submit data from the third quarter of 1998. After that, JCAHO will require quarterly reports on an ever-increasing number of performance indicators.

The Joint Commission will then review the submitted data, which surveyors will use during their triennial on-site accreditation surveys. Of particular interest to the surveyors will be how you use the data to analyze processes and improve patient care, says Deborah Nadzam, PhD, RN, vice president for performance measures at JCAHO.

"We’re going to look at the data by reviewing trends and patterns," Nadzam says. "Our primary interest initially will be whether the organization is using its data. If we see a trend that suggests the organization isn’t looking at its data, isn’t trying to make improvements, that will raise some questions in our minds." Specifically, the Joint Commission will ask for a written explanation for a lack of quality improvement within six to 12 months of data collection, and may ultimately send out a team of investigators.

Even with the end-of-the-year deadline fast approaching, much about ORYX remains up in the air, including exactly what it’s going to cost hospitals to implement it. Although the Joint Commission originally estimated that the cost would average only about $10,000 per hospital, Nadzam admits that, for some hospitals, that number could be off by as much as six figures. "All we really know about the measurement system costs is that the range is quite large," she says. "It’s really all over the map. And then of course the variable on top of that is whether or not the organization is automated and to what extent."

Automation is important because it affects the amount of human resources needed to collect the data ORYX requires. For example, most of the 60 or so performance measurement systems approved by JCAHO require electronic collection of data. "So the more automated an organization is, it will probably not have to do a lot of manual chart abstraction," Nadzam says. "Nor will it necessarily need to invest in new equipment."

At Underwood Memorial Hospital in Woodbury, NJ, the issue of automation will likely drive the decision of who is responsible for collecting ORYX data, says Marla Maybrook, manager of quality management. Although a final decision hasn’t been made, it’s likely that the hospital will initially rely on its coders for data collection. "We have so many case managers, but only three coders," says Maybrook. "And I believe that we’re going to be able to have more accurate information collecting it from three people compared to 10 or 12."

One factor that supports using coders for data collection at Underwood is that they are already familiar with the performance measurement system the hospital will be using for ORYX. Currently, the hospital’s case managers don’t use a computerized system.

However, Cynthia Whitaker, RN, BSN, CCM, president of the Case Management Society of America in Little Rock, AR, contends that case managers ultimately will have to be brought into the data-collection process. "They’re the ones who actually review the patients’ charts and work with patients to make sure they’re staying on track," Whitaker says. "I don’t know how coders could track the data just by looking at costs."

Establish relationship with vendor

Whoever handles the data is likely to face the challenge of coordinating with the performance measurement vendor on a very tight time frame, says Judy Homa-Lowry, RN, MS, CPHQ, of Homa-Lowry Consulting in Canton, MI. "If case managers are going to have any responsibility for the data collection, then they’re going to have to establish a relationship with the vendor because of the whole issue of data submission and edits. If people are not accustomed to that process of submission and resubmission, and there’s not good dialogue, then that could be very problematic."

Homa-Lowry says delays in reporting — and corresponding penalties from the Joint Commis sion — will be all but inevitable if case managers charged with data collection don’t receive appropriate training and assistance. "For those in a performance measurement system already, the data collection mechanism doesn’t change. It’ll probably be fairly seamless. But for those who are new to it, it could take a while to get comfortable with the process," she says.

Another implication for case managers is the possible impact ORYX will have on the development of clinical pathways. By the end of the year, hospitals will have to select clinical performance indicators that are pertinent to at least 20% of their patient population. By the end of 1998, that percentage will increase to 40%. Indicators include such measures as mortality rates for myocardial infarction (MI) and number of primary cesarean sections.

"Basically, you’re collecting numbers," says Maybrook. "Then you’re supposed to evaluate those numbers quarterly, because you get quarterly reports to see if you need to put something in place to improve the process. We’ll have to take action on our results, through case management and quality management."

The results of those quarterly reports are likely to exert a strong influence on the creation of new pathways, Maybrook says. "For example, if we find out that we have a very high C-section rate compared to other hospitals using this performance system, we may decide that we need a pathway to address that." By the same token, ORYX data could point out the need for revising existing pathways, Maybrook says.

"What [ORYX] should do, if it’s done appropriately, is give you some feeling for the outcome," says Homa-Lowry. "If the outcome isn’t desirable, then that would force a review of the process that contributed to the outcome." Such process reviews will be important, given the Joint Commission’s threat of conducting interim surveys any time submitted data don’t pass muster.

For the time being, the Joint Commission will compare data only among hospitals using the same performance measurement system. That’s a necessary concession because of the wide diversity among the different approved systems, Nadzam says. With about 60 systems already approved, another 40 invited to sign contracts for participation in ORYX, and an additional 100 currently under review, Nadzam admits that cross-system comparability is virtually impossible. "Right now, it really is apples, oranges, and bananas," she says. That situation may change in the future, however, as the Joint Commission moves to identify a common measurement set. "Once we have determined that, we would expect that systems would add these measures to their current menu of available measures," Nadzam says. "So it would not be quite as open as it is now, but it still would not go back to one system."

[Editor’s note: For more information about ORYX, contact:

Deborah Nadzam, PhD, RN, vice president for performance measures, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. Telephone: (630) 792-5085. Home page: http://www.jcaho.org.

Marla Maybrook, manager of quality management, Underwood Memorial Hospital, 509 N. Broad Street, Woodbury, NJ 08096. Telephone: (609) 845-0100.

Cynthia Whitaker, RN, BSN, CCM, president of the Case Management Society of America, 8201 Cantrell #230, Little Rock, AR 72227. Telephone: (501) 225-2229.]