The Joint Commission's new gunslinger could be good, bad, or just ugly
The Joint Commission’s new gunslinger could be good, bad, or just ugly
ORYX evolution can be friend or foe, depending on preparation
Just as the cloud of dust has started to clear and many providers now are prepared to handle the two-year-old subacute care accreditation process, the Joint Commission’s latest cowboy has galloped into town and stirred things up again.
Call it the ORYX initiative, a new gunslinger from the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations. ORYX is being touted as a critical link between accreditation and the outcomes of patient care.
Some providers say the Joint Commission’s new focus on outcomes comes as no surprise because of the health care industry’s trend in that direction.
"I think the Joint Commission has always maintained that this sort of activity is important, and we agree with that," says Nell Wood, director of marketing and communications for the Maryland Hospital Association in Lutherville. Maryland Hospital Association’s Quality Indicator Project is one of several approved by the Joint Commission for tracking outcomes. (For more information on Maryland Hospital Association’s list of outcomes indicators, see p. 63.)
But others question why they are being asked to take on extra expense and documentation when private companies already offer outcomes tracking services to those organizations that are interested.
Subacute care providers, as well as hospitals and long-term care providers, will have to collect data on outcomes of patient care and submit it to the Joint Commission on a quarterly basis. Long-term care organizations and hospitals that are accredited by the Joint Commission have been given until the end of the year to make some key decisions about tracking outcomes.
The chief deadlines are as follows:
• By Dec. 31, 1997, providers must choose a performance measurement system.
• Also, by Dec. 31, providers must select at least two clinical performance indicators from its measurement system, and these must relate to at least 20% of the patient population.
• In the third quarter of 1998, providers must begin data collection.
• In the first quarter of 1999, the data must be transmitted via computer to the Joint Commission.
• Data are transmitted each quarter after this.
Providers that fail to meet this year’s deadline will have to submit special progress reports to the Joint Commission, and they’ll be unable to attain accreditation with commendation. "But it won’t automatically put their accreditation into jeopardy," says Mary Kay Bowie, RN, MHSA, project manager of the research and evaluation department of the Joint Commission.
Meeting this new challenge won’t be easy, although the Joint Commission has tried to ease the transition by sending a 282-page book called ORYX Outcomes to every accredited hospital and long-term care organization.
Some experts say they fear it will be costly and time-consuming for many providers.
The Joint Commission conducted a field study of hospitals and long-term facilities and found that about one-third of the long-term care organizations responding to the survey said they participated in a performance measurement system, says Deborah Nadzam, PhD, RN, vice president of performance measurement for the Joint Commission.
The same survey also showed that the facilities’ expenses averaged less than $11,000 per year, Nadzam says. And many providers had added a full-time equivalent position to have someone gather the data.
Some providers question why they should invest time and money into a new outcomes tracking system when they have been using systems that already are available. Nadzam says the Joint Commission has contracted with some organizations that already provide outcomes tracking services, and this will allow some providers to continue using the same indicators they have been using. But many of the services either have had no indicators for long-term care, or the services are just beginning to develop some.
"When you think about how this is a time when everybody is trying to measure their costs, this $11,000 is a considerable cost," says Kathleen Leone, director of marketing high acuity services for Manor Care Health Services of Gaithersburg, MD. Manor Care has 180 skilled-nursing facilities in 28 states and offers a continuum of care from subacute to long-term care.
"We feel that $11,000 doesn’t really reflect the amount of time and expense for the staff to collect information, analyze it, and then you have to add the cost of getting the system accredited," Leone says.
Some providers, however, anticipate easily making the switch to ORYX because their outcomes tracking service already has contracted with the Joint Commission.
"We’ll use the same indicators for ORYX, and we’ll do more than two; we’ve been doing 19 basic ones and then some sub-indicators," says Tema Lacy, RN, administrative director for quality resource management at Desert Hospital in Palm Springs, CA. Desert Hospital has 398 beds and a skilled-nursing facility that’s licensed for short-term skilled care.
Lacy says the cost to Desert Hospital will be minimal. One of the few changes she anticipates is that the hospital will need to educate staff about gathering data "just to ensure that we all understand the indicators and that we understand the definition."
Bowie says the Joint Commission has 61 systems now listed and is reviewing another 42. "We’ll continue to add systems biannually after 1997," she adds.
Manor Care Health Services has been tracking outcomes since 1992 and has been working on its own system for six months, Leone says. "We believe strongly in outcomes tracking, but we are concerned that the board that is on this project doesn’t have many people who are familiar with the operational aspects of long-term care," she says.
Manor Care Health Services tracks outcomes on its subacute units through the Functional Independent Measure system (FIM) by Uniform Data System of Buffalo, NY, Leone says.
Uniform Data System’s FIM service has been selected by the Joint Commission to meet the ORYX system’s initial set of criteria, says Fran Hagerty, director of product development and marketing for Uniform Data, which has a national database of 1,200 facilities.
Some of the systems that have contracted with the Joint Commission have performance measures that apply to long-term care, Bowie says.
"If I were a hospital or long-term facility [administrator], I’d review the long-term systems listed with the Joint Commission to see which ones are applicable," she advises. (For information on performance measurement systems, see story, above.)
Leone questions how providers can benchmark their outcomes results against others through ORYX when so many different systems are being used. She gives an example of how difficult it might be to compare various facilities’ tracking of lengths of stay: "If everybody is using a different system, then they may be measuring the length of stay in a different way," Leone says. "If someone comes in at 7 a.m. and leaves by noon, does that mean they spent a day in the facility?"
Some systems will count this as a full day, and others will not, she says. So Leone wonders how these different measurements can be comparable.
Lacy says the ability to benchmark isn’t as important to Desert Hospital as the prospect of comparing its own progress in improving outcomes.
"I think it’s going to make hospitals and physicians look at their own practices, and managed care will look at their practices, and the Joint Commission will compare it eventually to other hospitals across the nation," Lacy underscores.
Nadzam says organizations will be able to compare their data with the performance of peers that are using the same measures and the same performance measurement system. For example, all subacute providers using FIM’s system will be able to benchmark their data with peers in the system.
But benchmarking is not the Joint Commission’s chief concern. ORYX was designed to help organizations identify problems and verify how effectively they are able to correct problems, according to the Joint Commission’s announcement of the initiative. Hospitals that want to participate in an expanded national database can voluntarily join ORYX PLUS, an option that allows hospitals to use a common set of measures on specific data. But the program is only available to hospitals for now.
Hagerty says Uniform Data System has been scrambling since the Joint Commission first announced the ORYX initiative in February to put together a packet of information about ORYX for hospitals and long-term care providers.
"We have been flooded with phone calls since this announcement," he adds.
Another trouble spot, Hagerty notes, is the Joint Commission’s requirement that the indicators apply to 20% of the facility’s population. "That’s just been sprung on everybody, and now they’re stepping back and trying to figure out what it all means."
Also, long-term facilities aren’t the typical customer base for the FIM system, so Uniform Data Systems is trying to figure out how to make FIM apply to the long-term setting, Hagerty explains.
Bowie says providers could meet the 20% requirement by selecting measures that relate to a problem area for the organization, such as infection rates. Then, the provider can look at the last year’s discharge data and infection rates to see how many patients were covered. If at least 20% of the patients were tracked for infection rates, then the agency is covered.
Another example of an indicator might be patients on ventilators, Bowie says. "Does the number of ventilated patients represent 20% of your population?"
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