SSI core measure: Look harder and look worse?
JCAHO may add post-discharge tracking
The thorny issue of post-discharge surveillance for surgical site infections (SSIs) threatens to undermine the accuracy of data reported on SSIs as a core quality measure to the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. The Joint Commission is aware of the problem, but it is not immediately clear how it is going to be corrected so that hospitals with the best post-discharge surveillance don’t appear to have the highest infection rates.
Under its ORYX initiative, introduced in 1997 to integrate outcomes and other performance measurements into the accreditation process, the Joint Commission is moving to a continuous data-driven accreditation process. The ORYX initiative was designed to be implemented in phases, with the use of nationally standardized core performance measures as a planned component. As approved by the Joint Commission and its advisory panels in February 2000, 25 core measures are planned under the following five areas: acute myocardial infarction, heart failure, pneumonia, pregnancy and related conditions, and surgical procedures and complications. The latter category includes SSIs within 30 days of the procedure and timing of antibiotic prophylaxis prior to surgery. (See related story, p. 52.) Acute care hospitals that serve patient populations whose conditions correspond to two or more of the core measure areas will be required to choose two measure sets from among the initial five by Sept. 1, 2001, according to the Joint Commission.
But difficult questions about the method and intensity of post-discharge surveillance used by hospitals tracking SSIs remain to be resolved if the core measure is to be accurate and effective, says Bryan Simmons, MD, a member of the Joint Commission advisory committee on the SSI core measure.
"[The committee] talked about surveillance intensity, that hospitals that do a worse job at surveillance will actually look better than hospitals that do a better job, particularly with post-discharge surveillance. But it was felt that we could not mandate that," he says. The panel reached an impasse when discussion turned to the resources needed and the unresolved issues of what type of post-discharge surveillance should be required (i.e., send cards or phone patients, contact surgeon, etc.). "[Committee discussions indicated] that this would be time-consuming and costly and still would not be exactly comparable because there is no one method of post-discharge surveillance that CDC or anybody else has recommended," Simmons says.
As a result, the advisory committee did not recommend a post-discharge surveillance component to the Joint Commission as part of the SSI core measure, though Simmons warned that those with the best surveillance programs could fall victim to misperceptions. "It was elected not to do this, but with full knowledge — at least by me, and I expressed this to the others there — that this may result in the hospitals doing the best job of post-discharge surveillance looking the worst," he tells Hospital Infection Control. "The data looks like 30% to 70% of infections that occur after surgical procedures are first detected after discharge from the hospital. So [even] if it’s only 30%, your rate will look 30% worse, everything else being equal."
The omission of an post-discharge SSI surveillance component did not go unnoticed by ICPs reviewing the core measures. "We know that there hasn’t been a single way to do it that has been documented to be the best," says Ona Baker Montgomery, RN, BSN, MSHA, CIC, infection control coordinator at the Veterans Affairs Medical Center in Amarillo, TX. "But most experts say you have to do something. Joint Commission, without specifying it, makes it awfully easy for hospitals to quite frankly do the opposite — not look — and just [use] passive surveillance, where a surgeon would call if they saw an infection. We know that doesn’t really work. Whereas, another hospital that is really serious about knowing their true infection information would go out and try to aggressively find [the infections]."
Joint Commission is aware of the problem and likely will take action to correct it as the SSI core measure specifications are finalized, says Jerod M. Loeb, PhD, vice president for research and performance measurement at the Joint Commission. "In view of the short lengths of stay today, I think of necessity it is almost without doubt that [the SSI core measure] is going to include some form of post-discharge surveillance," he tells HIC. "At this juncture, the specifics of that form of post-discharge surveillance — i.e., phone call, card, letter, or whatever — is unclear. All of [that] will be clarified as the measures have their specifications developed."
Addressing another major concern about the Joint Commission’s core measures program, Loeb emphasized that the selection of two infection control-related quality measures in no way lessens the importance of traditional infection control programs and standards. While some see the selection of infection control related measures as empowering for ICPs, there is also a question of whether the Joint Commission is moving away from its detailed infection control accreditation standards to a system of following a few quality indicators in the area.
"There were some concerns expressed that if the Joint Commission is moving toward looking at surgical site infections and timing of prophylaxis antibiotics, does that mean we are moving away from standards that have traditionally empowered infection control practitioners?" Loeb says. "The answer to that is unequivocally no.’ We are not moving away from [those] standards at all. Infection control is a very important function that is surveyed in all of the organizations that we go into. We have absolutely no intention of changing that. I want to make sure that people don’t [have] the impression that the idea of measuring these types of outcome or process measures is going to obviate surveyors looking at standards relating to infection control. That is not contemplated at all."
Going to continuous accreditation
But at the same time, it allows the traditional triennial accreditation process to be much more continuous and driven by data, he says. "When the surveyors get on site with data pertaining to these core measures, they will have information not only on how that organization has done against itself over time, but how that organization has done compared to other organizations," Loeb notes. "Both of the [surgical complication] measure groups that are moving forward end up relating to infection control, whether it be surgical site infection 30 days out or prophylactic antibiotic use. Clearly, [ICPs] are probably gratified that there is significant attention being paid to this."
While it is good that infection control was included in the process, the measures as currently proposed raise other difficult questions that will have to be answered if the project is to render meaningful quality improvement data, notes Baker. For example, another key question is whether health care facilities will be able to select from among the listed procedures for SSIs, she notes. A clear advantage of a "menu" selection would be to allow the facility to identify the procedures with greatest potential for improvement and impact on health outcomes for its population and focus on those. A disadvantage is that hospitals might choose only very-low-risk procedures with very low infection frequency to report, Baker notes. "If you can choose, why wouldn’t a hospital that wanted to look good just pick the ones that they knew were very low risk, that had very low infection rates?" she asks.
The procedures proposed in the core measure do not represent the final list, which will be honed down to a smaller selection, Loeb explains. "We have not yet identified which of these surgical procedures will be brought forward as the procedures to be chosen by hospitals. We are going to give them, in essence, a menu," he says. "While I can’t absolutely guarantee that there will not be gaming of the system, one of the requirements will be that you choose procedures that specially relate back to the high-volume, problem-prone kind of procedures. My hope is that people will play the game honestly and fairly, and if they don’t, it is probably going to be fairly obvious to surveyors on site."
(Editor’s note: Copies of the Joint Commission’s core measures and related documents can be found on the Internet at http://www.jcaho.org/permeas/coremeas/ cm_pub.html.)