Introduced in February 1997, The Joint Commission’s ORYX® initiative integrates outcomes and other performance measurement data into the accreditation process. ORYX measurement requirements are intended to support Joint Commission accredited organizations in their quality improvement efforts. In 2002, accredited hospitals began collecting data on standardized—or “core”—performance measures. In 2004, The Joint Commission and the Centers for Medicare and Medicaid Services began working together to align measures common to both organizations. These standardized common measures, called “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 both CMS and Joint Commission requirements.
All of the Hospital Quality Measures used by The Joint Commission and CMS are endorsed by the National Quality Forum. These measures are also utilized for the “Hospital Quality Alliance: Improving Care through Information” initiative, a voluntary public reporting initiative led by the American Hospital Association, the Federation of American Hospitals and the Association of American Medical Colleges. This initiative is supported by The Joint Commission, CMS, NQF, Agency for Healthcare Research and Quality, American Federation of Labor and Congress of Industrial Organizations, and AARP (formerly American Association of Retired Persons). Hospital Quality Measures and other core measure data are part of the priority focus process that is used by The Joint Commission to help focus on-site survey activities. These data are also publicly reported on The Joint Commission’s Quality Check® website, www.qualitycheck.org. The public availability of performance measurement data facilitates user comparisons of hospital performance and permits comparisons against overall national rates.
Current Hospital Quality Measure sets are for acute myocardial infarction (AMI), heart failure (HF), pneumonia (PN) and Surgical Care Improvement Project (the surgical infection prevention measures were transitioned into SCIP). In addition, The Joint Commission has core measure sets for pregnancy and related conditions (PR) and children’s asthma care (CAC).
Timeline for implementing new measures
The timeline for implementing new Hospital Quality Measures is below. Some timeframes rely on future NQF endorsement and HQA approval (caveats are noted).
- Surgical Care Improvement Project (SCIP):
- Two venous thromboembolism (VTE) measures—Effective with January 1, 2007 discharges.
- Three additional infection (Inf) measures—HQA approved; implementation date is pending NQF endorsement.
- One cardiac (Card) measure—HQA approved; implementation date is pending NQF endorsement.
- Three children’s asthma care (CAC) measures—HQA approved; effective with April 1, 2007 discharges. Two measures are NQF endorsed and one is pending NQF endorsement.
- Critical care measure set—Effective with January 1, 2008 discharges, pending NQF endorsement.
- Hospital-based inpatient psychiatric measure set—Will be tested in 2007 and then submitted to NQF for consideration of endorsement; an implementation date would be announced pending that endorsement.
At a later date, the following measures may be reported by The Joint Commission on Quality Check pending CMS implementation and an agreement between CMS and The Joint Commission for receipt of the data from CMS. While the data would be posted to Quality Check, it will not, at this time, be used as part of the priority focus process.
- Hospitals-Consumer Assessment of Healthcare Providers and Systems (H-CAHPS)
- Thirty-day mortality measures for acute myocardial infarction and heart failure
- Thirty-day pneumonia measure, pending NQF endorsement
General ORYX requirements
Currently, Joint Commission performance measurement requirements for hospitals can be satisfied by selecting three of the available measure sets. Hospitals that cannot identify three measure sets applicable to the patient populations they serve are required to collect a combination of core measure sets and non-core measures as follows:
- Two core measure sets and three non-core measures, OR
- One core measure set and six non-core measures OR
- Nine non-core measures (if none of the measure sets are applicable).
Data for all applicable measures must be submitted to The Joint Commission via a selected measurement system(s). Hospitals collect data according to the Specifications Manual for National Hospital Quality Measures, which is available on both the CMS and The Joint Commission websites. The manual is available on The Joint Commission website.
Requirements for small hospitals
Hospitals with an average daily census of 10 or less must meet the same general ORYX requirements outlined above, but are exempt from the requirement to transmit data via a selected performance measurement system to The Joint Commission. Small hospitals are required to:
- Collect data internally on all selected measures/measure sets.
- 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 critical access hospitals
Critical access hospitals are required to collect data internally on six non-core measures and share data conclusions with surveyors at the time of survey. Critical access hospitals are exempt from the requirement to transmit data via a selected measurement system to The Joint Commission. 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.
New ORYX requirements for 2008
New ORYX core measure and core measure set requirements have been established for Joint Commission accredited hospitals for January 1, 2008:
- If four applicable core measure sets can be identified, then no non-core measures are required.
- If three applicable core measure sets can be identified, then three non-core measures are required
- If two applicable core measure sets can be identified, then six non-core measures are required.
- If one applicable core measure set can be identified, then nine non-core measures are required.
- If no core measure sets are applicable, then nine non-core measures are required.
The Joint Commission is capping the non-core measure requirement at nine measures through 2009.