ORYX: There has to be a better way to do this’

More people on the front lines speak out

Hospital Peer Review asked Keith Young, director of data and information services at the Alabama Hospital Association in Montgomery, how his association came to be included among the 17 signatories to the letter to Dennis S. O’Leary, MD, president of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.

"The AHA [American Hospital Association in Chicago] coordinates monthly conference calls among the state hospital associations, and some include the Joint Commission," he explains. It was through such a conference call that the Alabama Hospital Association became party to the discussion. "Some state associations are more intimately involved with ORYX than we are because they provide data vendors to their hospitals," he says.

How was it that no more than 17 associations signed the letter? "The Joint Commission issued a news release asking for input on those core areas in late November," he says, "and their deadline was very brief — institutions had until Dec. 15 to reply. There wasn’t time for all the associations to find out about it, then to review the coordinating letter and get their names on it."

The Joint Commission’s decision-making process could be slower and a bit more deliberate, Young says. "ORYX is just now kicking in, and already changes are being made before there’s been time to work out the kinks. I think things are happening a little too fast."

Some hospitals were submitting between five and eight different indicators to get to their 20%, he explains. The first year’s reporting requirement was to cover 20% of patient population. "The Joint Commission had only supplied rough areas in which they wanted data collected, not specific measures or categories, so providers were choosing whatever they wanted," says Young. That was good in that it allowed facilities to choose those indicators most appropriate to their institution, which optimized their quality improvement projects. But the ORYX project became unwieldy, he says. The set of performance measures was too broad.

"Whether those 12 focus areas are meant to encompass the indicators a hospital reports on is cloudy at this point," says Young. "Some people have interpreted the requirement to mean that the focus areas are in addition to indicators already reported on. Others say the measures that a facility chooses to report on may not fit into one of those approved focus areas." Things have to get sorted out, he says. "The hospital associations really need to talk with the Joint Commission and figure these things out."

Discussions have been going on for months’

Becky Miller, director of performance measurement and quality at the Missouri Hospital Association in Jefferson City, also says her state association became involved in the letter through the twice-monthly conference calls. "Many times during those calls, we talk about Joint Commis sion issues or discuss comments we are hearing from our hospitals," she explains. "Issues relating to the core measurement initiatives have been discussed over the past several months by this group. We knew the initiative was going to get under way, and we had some concerns. This letter is just a culmination of those discussions that have been going on for several months."

The AHA took those issues and put them in letter format for the review of the 17 associations that were involved in the conference calls on an ongoing basis.

"The gist of our letter," says Miller, "gets down to process issues — how the Joint Commission develops new policies and new standards. Our concern is that the commission has not analyzed thoroughly the impact on hospitals of changing this performance measurement requirement. They haven’t gotten as much input from the field as they could have." They are going ahead without consulting those whom their decision influences most — hospitals. That’s the No.1 issue expressed in the letter, says Miller.

"I don’t recollect ever being asked by the Joint Commission for advice on these issues," she says. The state associations all employ staffs that are knowledgeable about Joint Commission regulatory issues, and they hear word from the field about the issues they’re dealing with. We’re in a position to — and are very willing to — provide input to the Joint Commission to make systems work better for our members, the commission, and health care in general," says Miller.

Susan White, vice president of quality management at the Florida Hospital Association in Orlando, agrees: "We’d like to be more involved in that process. The decision-making process would benefit if the state hospital associations played a more active role."

Hospital Peer Review asked Miller where she thinks this is headed. "I know where the Joint Commission wants to go with the ORYX initiative, and no one can deny we need a consistent method to measure quality before we can compare providers," she says. "We all agree on that. What we don’t agree on is how to do that without placing an undue burden on providers."

The Joint Commission, she says, has to look at its time line and make sure it is reasonable. "They are adding another level to their original time line with the core measure initiative," Miller says. "If they expect both initiatives to go forward, hospitals are going to be submitting an increasing number of non-core measures in addition to an increasing number of core measures."

The commission also should look at its current requirement on the number of measures hospitals should submit, she says.

"We already have confusion over the current ORYX initiative, and now we have something in addition to that before we have experience with the first initiative," says Miller. The initial ORYX initiative already is under way; hospitals started collecting data in July for the current initiative. "Before we’re off and running with that," she emphasizes, "now additional requirements are being thrust upon us."

Miller says she hopes the Joint Commission takes the state associations’ letter seriously and realizes there are many field resources from which to get input. "We need to all come together and figure out a better way to do this," she says.

Don M. Nielsen, MD, senior vice president for quality leadership at the AHA, told Hospital Peer Review he thought the responsiveness of the Joint Commission is a very positive sign. "I know we’ll be able to work together in coming to a successful resolution of these problems," he says. The state hospital associations and the Joint Commission both expect to be able to get to a core measurement data set, he says. "That’s everyone’s ultimate goal — a core standardized set of measures that can be used for quality improvement purposes as well as for purposes of accountability."

Nielsen agrees that there has to be more clarity around this issue. He says that just how the 12 focus areas are constituted in relation to the core data set was part of the issue raised by the associations’ letter and that he’s confident the question will be cleared up during the proposed forum.

The Joint Commission’s call for common core measures caused a great deal of concern, because issues were not clearly stated and because of a lack of involvement from state hospital associations, says Nielsen. "There is concern about the fact that there has been little input from the field in regard to this policy and its development," he continues. "I’m optimistic that the establishment of the forum is a positive step toward fixing this situation."

The associations expressed their concerns collectively, because, says Nielsen, "it was the combined feeling of these hospital associations that it would be more effective to write one collective letter than individual letters." The AHA facilitated the development of the letter and coordinated the different hospital associations.