ORYXâ is The Joint Commission’s performance measurement and improvement initiative, first implemented in 1997.
General ORYXâ requirements for hospitals
For 2008, hospitals are required to collect and transmit data to The Joint Commission for a minimum of four core measure sets or a combination of applicable core measure sets and non-core measures as described in the table below.
|
Applicable core measure sets |
Core measure sets required |
Non-core measures required |
|
4 core measure sets |
4 core measure sets |
None (data not accepted) |
|
3 core measure sets |
3 core measure sets |
3 non-core measures |
|
2 core measure sets |
2 core measure sets |
6 non-core measures |
|
1 core measure set |
1 core measure set |
9 non-core measures |
|
No core measure sets |
No core measure sets |
9 non-core measures |
The measure sets currently available for selection are:
- Acute myocardial infarction (AMI)
- Heart failure (HF)
- Pneumonia (PN)
- Pregnancy and related conditions (PR)
- Hospital-based inpatient psychiatric services (HBIPS) (Starting with October 1, 2008 discharges)
- Children's asthma care (CAC)
- Surgical Care Improvement project (SCIP)
- Hospital outpatient measures (HOP)
Data for all applicable measures must be submitted through a performance measurement system(s) that has been evaluated and listed by The Joint Commission. Hospitals collect data according to the following manuals:
Requirements for small hospitals
Hospitals with an average daily census of 10 or less must meet the same general ORYXâ requirements outlined above, but are exempt from the requirement to transmit data via a listed performance measurement system to The Joint Commission. Small hospitals are required to:
- Collect data internally on all selected measure sets/measures.
- Generate either run charts or control charts on each measure, at least quarterly, for use in internal quality improvement activities.
- Make data reports available for review by surveyors during on-site surveys, and produce the reports upon request of The Joint Commission for the purpose of data monitoring activities.
Requirements for freestanding children’s hospitals
Children’s hospitals that are “free-standing” facilities separately accredited by The Joint Commission (i.e., they are not surveyed and accredited as a site under the accreditation of the main Joint Commission accredited hospital), are required to collect and transmit data to The Joint Commission for the children’s asthma care (CAC) core measure set as well as data for nine non-core measures. The CAC core measure set is comprised of three performance measures:
- CAC-1: Use of relievers for inpatient asthma (effective with April 1, 2007 discharges)
- CAC-2: Use of systematic corticosteroids for inpatient asthma (effective with April 1, 2007 discharges)
- CAC-3: Home management plan of care given to patient/caregiver (effective with July 1, 2008 discharges)
Requirements for critical access hospitals
Critical access hospitals are required to collect data internally on up to four core measure sets or a combination of core measure sets and non-core measures as outlined in the table above. Critical access hospitals are exempt from the requirement to transmit data to The Joint Commission, however, they may transmit these data via a listed performance measurement system, if desired. If data are not transmitted, the organization will be expected to share data conclusions with surveyors at the time of survey. Critical access hospitals are encouraged to use the measure sets listed above, depending on patient population and the applicability of the measure sets to its services.
Background
Introduced in February 1997, The Joint Commission’s ORYXâ initiative was designed to integrate outcomes and other performance measurement data into the accreditation process. As such, ORYX measurement requirements were originally intended to support Joint Commission accredited organizations in their internal quality improvement efforts as assessed through the onsite survey process. Over time, data use has expanded in the accreditation process (i.e., the Priority Focus Process and the Strategic Surveillance System), for public reporting and accountability purposes, and for pay-for-performance initiatives (including the Reporting Hospital Quality Data Annual Payment Update process administered through the Centers for Medicare & Medicaid Services). Specifically, the Priority Focus Process helps The Joint Commission focus onsite survey activities. In addition, the data publicly reported on The Joint Commission' s Quality Check â website facilitates user comparisons of hospital-specific performance and permits comparisons against overall state and national rates.
In 2002, accredited hospitals began collecting data on standardized—or core—performance measures. In 2004, The Joint Commission and CMS began working together to align measures common to both organizations. These standardized common measures, called “National Hospital Quality Measures,” are integral to improving the quality of care provided to hospital patients and bringing value to stakeholders by focusing on the actual results of care. Measure alignment benefits hospitals by making it easier and less costly to collect and report data because the same data set can be used to satisfy CMS initiatives, the Hospital Quality Alliance (HQA), legislative, and Joint Commission requirements.
All of the National Hospital Quality Measures common to The Joint Commission and CMS are endorsed by the National Quality Forum (NQF) and are also used for the “Hospital Quality Alliance (HQA): Improving Care through Information” initiative. The HQA is a public-private partnership that was founded in 2002 for the purpose of developing a process for hospitals to voluntarily collect and publicly report their performance data. The HQA was initiated through the leadership of the American Hospital Association, the Association of American Medical Colleges, and the Federation of American Hospitals. HQA is supported by CMS, the Agency for Healthcare Research and Quality, NQF, The Joint Commission, the American Medical Association, the American Nurses Association, the National Association of Children’s Hospitals and Related Institutions, the National Association of Public Hospitals and Health Systems, the Consumer-Purchaser Disclosure Project, the AFL-CIO, AARP, U.S. Chamber of Commerce, America’s Health Insurance Plans, Blue Cross and Blue Shield Association, and the National Business Coalition on Health.
Future measure sets are anticipated to include venous thromboembolism (VTE), nursing-sensitive care, and stroke. It is The Joint Commission’s intention to remain in alignment with CMS so that the data collection efforts for hospitals can continue to be consolidated and minimized.
For more information
Call your account representative or the ORYXâ Information Line at (630) 792-5085, submit questions to oryx@jointcommission.org, or visit The Joint Commission website.