Here are the answers to your ORYX questions

Joint Commission director gives you the lowdown

First there was OASIS, and now there’s a similar measurement system called ORYX, which is a new requirement for accreditation by the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) of Oakbrook Terrace, IL.

ORYX data collection begins this quarter, and home care agencies will receive their first reports later this year. But as JCAHO-accredited agencies begin to collect data and analyze their first reports, there are some questions that arise.

Homecare Quality Management has asked Frank Zibrat, associate director of ORYX implementation, to explain how the system will work and clarify a few details that are puzzling some home care quality managers:

What are core measures and when will they be ready for home care agencies?

The Joint Commission is in the process of developing core measures that health care organizations could use for their indicators. Core measures are selected for the purpose of improving an organization’s quality of care, and they should be applicable to a large number of accredited organizations.

For example, five potential core measures for hospitals, selected by the Executive Committee of the JCAHO’s Board of Commissioners, are acute myocardial infarction, congestive heart failure, pneumonia, surgical procedures and complications, and pregnancy and related conditions.

We identified what we believe to be reasonable core measures for hospitals; we put those out for public comment and are in the process of evaluating the 2,000 responses that we got.

We’re also looking at core measures for home care, but have decided nothing at this point.

JCAHO has no timeline for when it will suggest core measures for home care agencies, although the organization will start the process this year of identifying core measures.

We’re looking at what makes sense from a clinical perspective and the perspective of providing health care organizations with the opportunity to identify opportunities to improve care. The core measure has to have clinical and statistical significance and be derived from data that’s readily available and already collected by the organization, and to come up with that combination is very difficult.

How can an agency make sure its performance measurement system is providing the most useful ORYX reports?

Some home care agencies might prefer to use a performance measurement system or ORYX vendor that has a high volume of other home care agencies so there will be a greater comparison in benchmarking reports. If volume is important, then the home care quality manager might ask the vendor how many agencies are using the vendor’s ORYX reports. Also, the Joint Commission soon will analyze its data on vendors and complete a list of the top 10 vendors, by volume, for home care.

For other agencies, a vendor might provide the best benchmarking data even if the vendor has only 50 agencies using ORYX reports. That vendor might have thousands of home care agencies that collect the same data, but only a few are using that data for ORYX purposes, for instance.

Quality managers should ask their vendors:

— What type of agencies contribute to your home care database and for what kind of purposes?

— How many agencies are using your database for ORYX reports?

— Are other agencies submitting data on the same measures our agency has selected as ORYX indicators?

— Has your company added home care data for comparison that it has collected from some other data system? And will this data be useful in doing benchmarking reports for ORYX?

— Does your company provide ORYX reports at least on a quarterly basis?

Adjusting risk

What is risk adjustment and how important will that be to the ORYX reports?

Each home care agency serves a different client population. Some may serve healthier, younger surgery patients, and others may have a patient base that is mostly frail and elderly. A home care agency’s outcomes depend partly on the health of its patients. A quality manager, for instance, wouldn’t expect a bed-bound 85-year-old woman with diabetes to recover from a wound as quickly as a 35-year-old woman recovering from hip surgery. This is why quality managers want their benchmarking reports to be risk adjusted. If they’re not, then a particular agency might appear to be doing worse than its peers when actually, given its frail and very sick patient population, it’s doing much better than would be expected.

Risk adjustment is difficult to do, and each performance measurement system will have a different risk adjustment methodology, when these are available at all.

JCAHO recommends risk adjustment, but does not require or offer any methodology for it. Agencies will have to depend on their ORYX vendors for any risk adjustment in the ORYX benchmarking reports.

The more sophisticated systems will use risk factors beyond simply the demographic or administrative type of risk factors.

To obtain the most meaningful risk adjustment will take more time and money. It simply becomes an issue of cost, what one might be willing to pay for, and what the measurement system might view as an appropriate risk adjustment methodology.

Here are some questions to ask the ORYX vendor about risk adjustment:

— Do you provide risk adjustment?

— Which measures are risk adjusted?

— What is your methodology for doing risk adjustment?

— Do you use patient level factors or some other types of factors?

— Are these truly demographic factors?

— Do you also include some patient specific factors, such as comorbid conditions or whether a cardiac patient has a history of smoking?

What is the timeline for ORYX reporting?

Home care agencies accredited by JCAHO were required to begin collecting ORYX data Jan. 1, 2000. Their first quarter data is due by July 31, 2000. Since all home care agencies will be sending their data to a performance measurement system, they’ll have to turn in their data to that vendor sometime well before the deadline.

By the end of the year, home care agencies will have to add two additional clinical or perception-of-care measures to the four ORYX indicators they’re already collecting.

How will ORYX reports affect an agency’s accreditation survey?

Agencies will not be scored based on their ORYX reports; but if the agency is not participating in collecting ORYX measures the agency will receive a special Type 1 recommendation, and failure to correct this could lead to loss of JCAHO accreditation.

JCAHO surveyors will also review ORYX reports as part of the survey process. For example, suppose a home care agency’s ORYX report shows a high rate of central line infections. The surveyor might ask the agency, "Why is that rate high? Are you doing proper assessment of the patient before you take the patient off of the service, or have you assessed whether this patient should be in home care?

The surveyor also might look at what kind of home environment and support system the patient has, and whether the patient has other medical conditions that make him or her more susceptible to infections.

These are some of the questions the surveyor would want to inquire about and see what you as the organization might be doing to provide the best possible care of the patient. These questions are asked, and then it gets into standards issues.

In other words, the ORYX reports simply give the surveyor yet another source of information on which to determine how well the organization is following its own standards, as well as Medicare, JCAHO, and state standards.

The surveyor can take this information and tuck it away in the back of the head; and as the surveyor goes through the process, there may be certain things that he or she sees or hears that may trigger some more pointed questions that relate to standards issues.

Performance measurement systems should provide home care agencies with regular written reports, so quality managers can keep track of an agency’s progress on the four ORYX indicators.

However, ORYX reports also will be issued from JCAHO about 30 days before the agency is next surveyed, starting in the second half of 2000.

JCAHO will provide the health care organization with the same report provided the surveyor. It will have a summary page, control charts, and comparison charts.

This way, the agency will have 30 days to review the report and prepare any answers to potential questions from the surveyor.