What is the current process for transmitting performance measurement data to the Joint Commission?
Individual patient data is gathered by the hospital and transmitted to a performance measurement system. The vendor aggregates the data at the organization level and transmits it to the Joint Commission.
What is the potential change for transmitting performance measurement data to the Joint Commission?
The Joint Commission proposes that case-identifiable data be sent to the Joint Commission by the ORYX® performance measurement systems.
Why does the Joint Commission need case-identifiable data?
To improve the specificity of the accreditation process by verifying the accuracy of the core measure data, minimizing data calculation and aggregation errors, application of risk adjustment models, and confirming that the data are as complete as possible. This information can also be used to improve measures, measure definitions, abstraction guidelines, etc.
The Joint Commission approves the performance measurement systems for use by accredited hospitals; aren’t they doing a good job?
While the Joint Commission monitors the performance of its measurement system vendors, it does not have access to case-identifiable data. As a result, the accuracy and completeness of the data cannot be verified to the extent necessary given the critical current and future uses of performance measurement data.
What is the benefit of the Joint Commission receiving case-identifiable data?
In addition to being able to independently verify accuracy, the Joint Commission would be able to provide hospitals with greater assurance that their data, and the data of other facilities, are sufficiently accurate to permit fair comparisons. Case-identifiable data would allow the Joint Commission to identify missing data elements and determine whether measure populations are being captured correctly. In addition, the Joint Commission would be able to centrally calculate all measure rates rather than rely on more than 50 measurement system vendors to do separate computations.
Can the Joint Commission obtain the case-identifiable data from the Centers for Medicare and Medicaid Services (CMS)?
No. The performance measurement systems transmit case-identifiable data to the Iowa Quality Improvement Organization (QIO). The QIO provides CMS with an aggregate report. The QIO does not have the authority under current regulation to give the Joint Commission access to this database. Even if access were permitted, the QIO database does not include all core measure sets (e.g., maternal/newborn), nor does it contain data on all Joint Commission-accredited hospitals (e.g., Veteran’s Administration and Department of Defense hospitals).
What data would be collected?
Through your performance measurement system, the Joint Commission would collect all individual data elements associated with your hospital’s selected core measure sets. Some of these elements are considered protected health information (PHI). They relate mostly to dates ― date of admission, surgery start date, surgery end date, discharge date, etc. The Joint Commission does not need specific patient identifiers such as name or social security number. A unique case identifier or tracking number could be substituted for these patient identifiers.
Would this require more data abstraction or audits by hospitals?
No. Hospitals will continue to submit data to their performance measurement systems as they have in the past. The Joint Commission would then work with performance measurement systems to obtain the case-identifiable data and to ensure the accuracy and validity of the reported data.
How would the data be obtained?
Based upon field input, the Joint Commission is currently considering the following mechanism:
- Upon receiving case-identified data from a hospital, the performance measurement system would remove specific patient identifiers ― patient name, social security number or Medicare number ― which are not needed for Joint Commission purposes.
- The performance measurement system would then assign a unique tracking number to each case to facilitate the measurement system’s review of the case in the event that the Joint Commission needs further clarification on the accuracy or completeness of the data.
- The performance measurement system would then transmit case-identified (but not patient-identified) data to the Joint Commission on a quarterly basis.
Would our performance measurement system charge us more to send case-identified data to the Joint Commission?
Each performance measurement system will be looking at the ramifications of sending case-identifiable data to the Joint Commission. The Joint Commission is asking for clarification from the performance measurement systems about the cost implications, if any, of this potential policy change.
Would our accreditation fees go up as a result of the Joint Commission receiving and processing case-identifiable data?
No.
Do we still need to use a performance measurement system if the Joint Commission is going to receive case-identifiable data?
Yes. Your performance measurement system will continue to send you timely quarterly reports about your performance. The Joint Commission would then aggregate the data and calculate rates from all 50 performance measurement systems. Besides, performance measurement systems provide a wide array of services to their client hospitals including, data processing, electronic data collecting, additional measures for improvement, drill down tools, training and education.
Will the Joint Commission provide more useful data analysis reports to accredited organizations?
In 2007, the Joint Commission is planning to launch a Strategic Surveillance System (S3) tool based on the Priority Focus Process to guide the survey. The quarterly S3 reports will provide comparative data to accredited hospitals in 14 priority focus areas and 32 clinical service groups. Testing indicates a strong correlation between these scores and how the organizations actually do on their surveys.
Does the Joint Commission plan to sell case-identifiable data?
No. The Joint Commission has never sold nor given away case-identifiable or patient-level data and will not do so in the future. In fact, the Board of Commissioners has approved a policy prohibiting the Joint Commission from selling even organization-level data to third parties. Additionally, hospitals can sign an amendment to their accreditation contract stating that the Joint Commission will not profit from the sale of any data (the amendment is available on the Extranet site for accredited organizations).
What type of public access would there be to the case-identifiable data?
None. The Joint Commission will never allow public access to case-identifiable data.
Do other entities receive case-identifiable data?
Yes. Performance measurement systems, including state hospital associations that have performance measurement systems and Quality Improvement Organizations receive case-identifiable data on a regular basis.
Does the Joint Commission currently have access to case-identifiable data?
Yes. The Joint Commission accesses case-identifiable data during the survey, in sentinel event reports, and in complaints. In addition, the measurement systems send a 20 percent sample of case-identifiable data for hospital performance measures that require risk adjustment, e.g., AMI inpatient mortality and newborn/maternal performance measures.
Does this plan create a HIPAA compliance risk for Joint Commission-accredited hospitals?
No. The Office of Civil Rights has stated that under HIPAA’s “minimum necessary” standard, HIPAA allows a covered entity (such as a hospital) to rely on the judgment of a business associate (the Joint Commission) when the business associate affirms that the information requested is the minimum necessary for the stated purpose ― in this case, in support of activities directly related to improving the accreditation process.
Is this a duplication of the chart-level validation that CMS conducts?
No. CMS looks at the reliability of the data on a very small sample of cases ― five cases per quarter, 20 cases per year per hospital. The Joint Commission would look at all the data for all accredited hospitals and identify patterns and trends.
Is the Joint Commission working with other entities to obtain a national alignment of performance measurement requirements?
Yes. The Joint Commission continues to work closely with both CMS and the Hospital Quality Alliance to align its measurement and reporting activities to the fullest extent
possible.
What is the timeline for this project? Is it a done deal?
The Joint Commission has made no decisions about the proposal to access case-identifiable data. We are currently soliciting input from the field on this topic. We will discuss results of our information gathering activities with the Board of Commissioners at its July and November 2006 meetings.