ORYX: What’s Next?

Joint Commission jettisons ORYX Plus in favor of core measures reporting

Disgruntled hospitals, vendors warily await JCAHO’s next move

If it’s three strikes and you’re out, the Joint Commission has got to be worried that it is perilously close to blowing its chances for convincing hospitals it is the organization to coordinate electronic reporting of outcomes data for quality assurance.

In late May, the Joint Commission’s Executive Committee voted to pull the plug on ORYX Plus, the Cadillac version of its ORYX electronic outcomes reporting program. It will cease to be supported past May 31, 2000.

This marks the second major setback for the ORYX program, which was launched in late 1997 by the Joint Commission on Accredita tion of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL. In January, hundreds of hospitals protesting the basic ORYX program forced the Joint Commis sion to address complaints about the program’s lack of standards, the Joint Commission’s high-handed approach in imposing the program with little or no input from hospitals, and the program’s mushrooming costs.

The result of those negotiations was that the Joint Commission is now busily retrofitting the program with a group of "core performance measures" that will have standard definitions and will be developed with input from hospitals. Just where this effort will go and what it will cost is the focus of current debate on ORYX.

But JCAHO has been on this ground before. In the early 1990s, it failed to get the industry to adopt a performance measurement system called the Indicators Measurement System. So, arguably, this is the Joint Commission’s third embarrassing failure at setting up a central database of quality performance measures.

By any count, the industry’s patience for JCAHO’s failures is wearing thin, both among the hospitals it regulates and among health care software vendors. The vendors now find themselves in the middle of another JCAHO about-face, which will require them to redesign existing packages or develop new software programs to accommodate the new initiative on core performance measures.

In an era of mergers, consolidation, hospital cutbacks, and strained budgets, the Joint Commission cannot afford another failure that wastes scarce hospital dollars while returning little or no benefit to the industry.

This latest retrenchment of the Plus program affected only a handful of hospitals and vendors, because no more than 25 hospitals ever signed on for the expansive program. ORYX Plus required its participating members to report electronically on 10 different outcomes. Once the data are risk-adjusted for comparison purposes, they are published for public consumption.

Costs for initiating ORYX Plus, depending on existing hardware and software, could easily run a hospital $100,000. This is substantially more ambitious, at least on paper, than the basic ORYX program, which is being phased in over a four-year period and requires hospitals to initially report only two or three outcomes (or 20% of its patient base) at a basic initiation cost of about $10,000.

"I think the Joint Commission just changed its thinking halfway through the process," says Judy Finlan, director of clinical consulting services at the New Jersey Hospital Association (NJHA) in Princeton. The New Jersey association was one of 17 state hospital associations that signed a letter of protest in January that resulted in the new core performance effort.

"Why is ORYX Plus dying?" Finlan asks rhetorically. "First, there wasn’t a lot of interest in it. Not one New Jersey hospital participated, and there was not exactly a groundswell of interest nationwide — a very small number of hospitals signed on. Second, hospitals thought, if it’s going to be replaced by core measures soon, why get into ORYX Plus?"

Jean Chenoweth, senior vice president at HCIA in Baltimore, a vendor of ORYX and ORYX Plus systems, agrees. "Hospitals saw that the work involved would be much more extensive than reporting a couple of items, and it would have been very difficult for them," she says. "There didn’t seem to be much payback at all. It was not as though you were adding on another half-hour of effort to report a little more data. The data collection required a large effort."

Another vendor, Leonard Rogers, CEO of Health Care Data in Encinitas, CA, is critical of JCAHO’s timing. "I’m not bashing the Joint Com mission and saying what they did was wrong, but the timing was awful," he says. "We spent a lot of money on programming to make this thing happen. An entrepreneurial business like ours puts a lot of money into resources and program development. We put forth a lot of effort, and now it’s stopping. It was our expectation that ORYX Plus would go on until the end of 2000 or at least until core measures were ready to be brought forward to the hospitals for consideration."

And Rogers voiced a common complaint from hospitals and vendors alike: "It’s confusing to organizations when you start and stop programs. Hospitals no sooner put processes in place than they have to switch to something else."

Disgruntlement in many camps

A vendor who commented only on condition of anonymity for fear that his company might be blacklisted from future JCAHO-approved vendor lists says many ORYX Plus vendors are incensed. "Most say this move on the Joint Commission’s part is awful after all the time and effort they put into it." He says many hospitals are upset as well because they had "the rug pulled out from under them." Although many hospitals like the ORYX Plus outcomes measures, they resent wasting that time and effort, he says, adding, "there’s a lot of disgruntlement in many camps."

Another vendor, who also wanted anonymity, told Hospital Peer Review, "The American Hospital Association has been quiet over the past six months, but the membership has been critical of the Joint Commission and its ORYX initiative. Most people don’t think the program is going to have much effect at all on what hospitals do."

It is this uncertainty regarding the Joint Com mission’s ability to accomplish what it proposes that most threatens its credibility in the industry. Taken alone, these failures might be overlooked, but over the past two years JCAHO also has been repeatedly and publicly criticized for its failures to do the basic jobs for which it exists.

In 1998, the Health Care Financing Admini stra tion questioned JCAHO’s surveying techniques in light of ongoing quality problems, as well as huge Medicare/Medicaid fraud, estimated to be $23 billion that year. It sent Office of Inspector General auditors along on a number of JCAHO surveys to monitor surveyors’ techniques.

Some questioned at the time whether HCFA might be threatening to pull the Joint Commis sion survey’s "deemed status," which makes it possible for JCAHO-surveyed organizations to bypass a possible annual HCFA audit in order to participate in the Medicare and Medicaid programs.

"I think one can see where the dots are being connected," Fay A. Rozovsky, JD, MPH, DFASHRM, principal of the Rozovsky Group, Richmond, VA, told Compliance Hotline, a sister publication to HPR, in June 1998. "What the Joint Commission is concerned about, of course, is its own credibility and public trust in the whole accreditation process." HCFA’s report on the audit of JCAHO surveyors has yet to be made public.

Should JCAHO lose deemed status privileges, its reason for existing would be severely compromised. Many hospitals undergo a Joint Commis sion survey primarily to avoid HCFA or state audits, which look at many of the same quality issues JCAHO does but open the hospital to government scrutiny anywhere in the hospital. If such an audit were no longer avoidable, there would be little justification for submitting to the costly Joint Commission survey.

Even as ORYX Plus slides into oblivion, many hospitals don’t clearly understand just what the initiative tried to accomplish. It was expected that ORYX Plus hospitals would represent the top hospitals and become recognized by consumers, employers, payers, and government bodies for their commitment to self-evaluation and accountability through their willingness to share performance information with the public.

The Joint Commission also intended to develop a form of special recognition for ORYX Plus hospitals. But by the end of 1998, only 25 hospitals across 17 states participated in the project. These were primarily general medical-surgical facilities, but also included children’s, teaching, and military hospitals. They range in size from 60 to 723 beds.

Although ORYX Plus did not have the problems of lack of standards and risk adjustments found in the basic ORYX program, the program was DOA anyway because of low participation. Recognizing this, the Joint Commission late last year proposed to retrofit basic ORYX with standard core performance measures.

That announcement was the last straw for many hospitals, which saw JCAHO-developed core measures as a bandaid measure that could cost individual hospitals thousands of dollars in customization of software. A groundswell of discontent and revolt surfaced in a letter sent in January by 17 hospital associations to JCAHO, expressing dissatisfaction and their intention to halt participation in ORYX unless the Joint Commission listened to their demands and took input from the hospitals themselves. (See related story, HPR, March 1999, p. 37.)

The Missouri Hospital Association in Jefferson City was one of the signatories. Becky Miller, director of performance measurement and quality at the association, told HPR that JCAHO president Dennis O’Leary’s response to the letter has been generally positive. "We’ve gotten good feedback from our hospitals," she says. "We’re especially interested in seeing what the finalized core measures will be and what they will mean for individual hospitals who participate in collecting and reporting them." She says Missouri hospitals have provided input to JCAHO on areas in which they would like to see core measures developed.

"We’ve only been involved from that perspective," she explains. "We haven’t spent money to meet core measures so far."

The Alabama Hospital Association in Montgomery also signed the protest letter, and Keith Young, director of data and information services for the association, says hospitals in his state are not happy with the Joint Commission’s performance on ORYX. "Hospitals here are concerned," Young says, "because they see JCAHO adding programs midstream without having evaluated them — without knowing if they’re going to fly." He says JCAHO acts without knowing whether the programs it initiates will be a manageable load for the Joint Commission or for hospitals, and without knowing if hospitals can adequately implement the goals of a project.

"Then when the Commission added core measures, that raised questions," he says. People were concerned that the new process wasn’t adequately spelled out, and they worried about having an additional burden, Young says. "It’s one thing to decide that the current program doesn’t work and isn’t accomplishing a goal, but now they’ve recalled ORYX Plus and say we are moving to core measures. It’s clouding the situation."

A third signer of the letter written to JCAHO in early January was the NJHA. Ceil Stern, director of accreditation and licensure for the association, says while no New Jersey hospitals were ORYX Plus participants, they have been transitioning to core measures over the past few months. "We support their use," she says, although her organization had concerns about how JCAHO was implementing the program.

"The problems were with the implementation of ORYX and its time frames, and how decisions were being made," Stern says. "We had no disagreement that core measures are a good idea, only with the manner in which the whole process of performance measurement reporting would be rolled out."

Like her counterparts elsewhere in the nation, Stern is worried about investing so heavily in programs with short life spans. "We were afraid that after investing a lot of money in ORYX, it would become obsolete," she says. "Then with the transition to core measures, we wondered if the vendors the Joint Commission selected would want to continue. The rules were changing too fast."