vermont hospital association and mha management services corporation may 2, 2002
TRANSCRIPT
Vermont Hospital Association
and MHA Management Services
Corporation
Vermont Hospital Association
and MHA Management Services
CorporationMay 2, 2002May 2, 2002
Objectives for Today
Objectives for Today
Learn about Joint Commission’s perspective on measurement in health care
Learn about Joint Commission’s evolution to ORYX® core measures
Learn about implementation of ORYX® core measures and its impact on hospitals
Learn about MHA’s ORYX® measurement system and QualityWorks
Learn about Joint Commission’s perspective on measurement in health care
Learn about Joint Commission’s evolution to ORYX® core measures
Learn about implementation of ORYX® core measures and its impact on hospitals
Learn about MHA’s ORYX® measurement system and QualityWorks
JCAHO Critical Measurement Issues
JCAHO Critical Measurement Issues
#1 - Need to align measurement activities across various organizations
#2 - Need for consensus-generated framework for measurement (clinical, health status, perception of care, financial/administrative)
#3 - Move from condition-specific measures to site-specific measures
#1 - Need to align measurement activities across various organizations
#2 - Need for consensus-generated framework for measurement (clinical, health status, perception of care, financial/administrative)
#3 - Move from condition-specific measures to site-specific measures
JCAHO Critical Measurement Issues
JCAHO Critical Measurement Issues #4 - Need for consensus-generated,
standardized format for reporting perceptions of care in hospitals
#5 - Joint Commission disease specific care certification program
#6 - Lack of agreement on a format for public reporting of measurement data
#4 - Need for consensus-generated, standardized format for reporting perceptions of care in hospitals
#5 - Joint Commission disease specific care certification program
#6 - Lack of agreement on a format for public reporting of measurement data
JCAHO Critical Measurement Issues
JCAHO Critical Measurement Issues
# 7 - Phenomenon of small numbers, multiple measures are needed to provide the picture of quality
#8 Enhancing the value of measurement to make it meaningful to providers, patients and public
# 7 - Phenomenon of small numbers, multiple measures are needed to provide the picture of quality
#8 Enhancing the value of measurement to make it meaningful to providers, patients and public
Anatomy of JCAHO Performance Measurement
Anatomy of JCAHO Performance Measurement
1987 - Joint Commission’s Agenda for Change 1995 - JCAHO Advisory Council on Performance
Measurement Pre 1997 - Joint Commission’s IMSystem 1998 - ORYX® was launched 1999 - Determined process may need to be changed 2000 - ORYX® core measure pilot project launched
2002 - ORYX® core measures implemented
1987 - Joint Commission’s Agenda for Change 1995 - JCAHO Advisory Council on Performance
Measurement Pre 1997 - Joint Commission’s IMSystem 1998 - ORYX® was launched 1999 - Determined process may need to be changed 2000 - ORYX® core measure pilot project launched
2002 - ORYX® core measures implemented
ORYX®: The Next Evolution in
Accreditation
ORYX®: The Next Evolution in
Accreditation Accreditation Participation Requirement National set of measures for comparative
purposes Use of data as part of the accreditation process Focus survey activities Provide focus for accredited organizations
Accreditation Participation Requirement National set of measures for comparative
purposes Use of data as part of the accreditation process Focus survey activities Provide focus for accredited organizations
A Changing FaceA Changing Face Pre 1997 - IMSystem - one performance
measurement system option 1998 - ORYX® implementation
~ 300 performance measurement systems ~8,000 disparate measures
2002 - ORYX® core measure implementation 4 measure sets 22 defined measures
Pre 1997 - IMSystem - one performance measurement system option
1998 - ORYX® implementation ~ 300 performance measurement systems ~8,000 disparate measures
2002 - ORYX® core measure implementation 4 measure sets 22 defined measures
Status of ORYX® Systems
(as of January 2002)
Status of ORYX® Systems
(as of January 2002) Total listed systems = 186 Total possible new systems = 30 Total systems withdrawn since
beginning of ORYX® initiative = 155 Total systems that have signed an
agreement for core measures = 40
Total listed systems = 186 Total possible new systems = 30 Total systems withdrawn since
beginning of ORYX® initiative = 155 Total systems that have signed an
agreement for core measures = 40
The Evolution to ORYX® Core Performance Measurement
The Evolution to ORYX® Core Performance Measurement Driven by the need for valid, reliable,
evidence-based measures Early 1999 - solicited input from various
stakeholders about possible core measure sets
JCAHO Board selected five initial sets of measures (AMI, HF, CAP, Pregnancy, Surgery)
Driven by the need for valid, reliable, evidence-based measures
Early 1999 - solicited input from various stakeholders about possible core measure sets
JCAHO Board selected five initial sets of measures (AMI, HF, CAP, Pregnancy, Surgery)
The Evolution to ORYX® Core Performance Measurement
The Evolution to ORYX® Core Performance Measurement Expert panels developed 29 measures
submitted for comment February 2000 - JCAHO Board approved 25 of
the initial 29 core measures December 2000-December 2001 - ORYX® Core
Measure Pilot Project November 2002 - final specifications released July 2002 - launch of core measures
Expert panels developed 29 measures submitted for comment
February 2000 - JCAHO Board approved 25 of the initial 29 core measures
December 2000-December 2001 - ORYX® Core Measure Pilot Project
November 2002 - final specifications released July 2002 - launch of core measures
ORYX® Core Measure Pilot
Project
ORYX® Core Measure Pilot
Project 5 state hospital associations and
performance measurement systems Connecticut (7 hospitals) Georgia (28 hospitals) Michigan (20 hospitals) Missouri (18 hospitals) Rhode Island (10 hospitals)
5 state hospital associations and performance measurement systems Connecticut (7 hospitals) Georgia (28 hospitals) Michigan (20 hospitals) Missouri (18 hospitals) Rhode Island (10 hospitals)
Pilot Measure SetsPilot Measure Sets
Congestive heart failure Acute myocardial infarction Pneumonia
Congestive heart failure Acute myocardial infarction Pneumonia
Demographics of Pilot Sites
Demographics of Pilot Sites
< 50 beds - 9 hospitals 51-100 beds - 22 hospitals 101-200 beds - 15 hospitals 201-400 beds - 24 hospitals > 400 beds - 14 hospitals
< 50 beds - 9 hospitals 51-100 beds - 22 hospitals 101-200 beds - 15 hospitals 201-400 beds - 24 hospitals > 400 beds - 14 hospitals
Pilot Project Results
Pilot Project Results
Cooperation between CMS and JCAHO on measure sets and definitions
Reliability visits in 16 hospitals revealed AMI 88%, HF 91%, CAP 87%
Identified technical issues Identified statistical issues Changes in measures and specifications An idea of resource requirements
Cooperation between CMS and JCAHO on measure sets and definitions
Reliability visits in 16 hospitals revealed AMI 88%, HF 91%, CAP 87%
Identified technical issues Identified statistical issues Changes in measures and specifications An idea of resource requirements
ORYX® Core Measure SetsORYX® Core Measure Sets
AMI aspirin at arrival aspirin at discharge ACEI for LVSD smoking cessation advice beta blocker at discharge beta blocker at arrival time to thrombolysis time to PTCA
inpatient mortality
AMI aspirin at arrival aspirin at discharge ACEI for LVSD smoking cessation advice beta blocker at discharge beta blocker at arrival time to thrombolysis time to PTCA
inpatient mortality
HF discharge instructions LVF assessment ACEI for LVSD smoking cessation
advice
HF discharge instructions LVF assessment ACEI for LVSD smoking cessation
advice
ORYX® Core Measure SetsORYX® Core Measure Sets
Pneumonia oxygenation assessment pneumococcal screening
and/or vaccination blood cultures smoking cessation
advice pediatric smoking
cessation advice antibiotic timing
Pneumonia oxygenation assessment pneumococcal screening
and/or vaccination blood cultures smoking cessation
advice pediatric smoking
cessation advice antibiotic timing
Pregnancy VBAC inpatient neonatal
mortality third or fourth degree
laceration
Pregnancy VBAC inpatient neonatal
mortality third or fourth degree
laceration
ORYX® Core Measure Timeline
ORYX® Core Measure Timeline
By July 2002 - accredited hospitals select core measure vendors and measure sets
Beginning with July 2002 discharges - accredited hospitals collect data on selected measures
January 2003 - first set of ORYX® core measure data submitted to JCAHO by systems
Subsequent quarters - sets of data submitted to JCAHO by systems
By July 2002 - accredited hospitals select core measure vendors and measure sets
Beginning with July 2002 discharges - accredited hospitals collect data on selected measures
January 2003 - first set of ORYX® core measure data submitted to JCAHO by systems
Subsequent quarters - sets of data submitted to JCAHO by systems
Measure Set Selection
Requirements
Measure Set Selection
Requirements If hospital treats at least two of the
patient populations covered by the core measure sets select those sets for transmission of all
measures in the set to JCAHO by the system
If hospital treats at least two of the patient populations covered by the core measure sets select those sets for transmission of all
measures in the set to JCAHO by the system
Measure Set Selection
Requirements
Measure Set Selection
Requirements If hospital treats only one of the patient
populations covered by the core measure sets select that set and 4 non-core measures for
transmission to JCAHO
If hospital treats only one of the patient populations covered by the core measure sets select that set and 4 non-core measures for
transmission to JCAHO
Measure Set Selection
Requirements
Measure Set Selection
Requirements If hospital does not treat patients in any
of the core measure sets select 6 non-core measures for submission
to JCAHO
If hospital does not treat patients in any of the core measure sets select 6 non-core measures for submission
to JCAHO
Measure Set Selection
Requirements
Measure Set Selection
Requirements If hospital has an average daily census
of less than 10 select 6 non-core OR applicable core measure sets data does not have to be submitted to
JCAHO
If hospital has an average daily census of less than 10 select 6 non-core OR applicable core measure sets data does not have to be submitted to
JCAHO
SamplingSampling
Allowed if monthly population size of a measure set is at least 75 cases
Maximum required sample size is 200 Simple random sampling OR systematic
random sampling methods
Allowed if monthly population size of a measure set is at least 75 cases
Maximum required sample size is 200 Simple random sampling OR systematic
random sampling methods
Risk AdjustmentRisk Adjustment Risk adjusted measures
AMI Mortality rate VBAC Inpatient neonatal mortality rate Third or fourth degree laceration
System submits de-identified patient-level data to JCAHO to develop risk models, file provided to systems to calculate predicted rates and submit risk adjusted data
Risk adjusted measures AMI Mortality rate VBAC Inpatient neonatal mortality rate Third or fourth degree laceration
System submits de-identified patient-level data to JCAHO to develop risk models, file provided to systems to calculate predicted rates and submit risk adjusted data
ReportingReporting
Required Control charts Comparison charts
Additional reports possible
Required Control charts Comparison charts
Additional reports possible
ORYX® Requirements for Other Accreditation
Programs
ORYX® Requirements for Other Accreditation
Programs Home Care/Behavioral Health Care
use a system, collect 6 measures, transmit data, exemptions for very small organizations
Healthcare Networks select from defined sets of measures, data
transmission
Home Care/Behavioral Health Care use a system, collect 6 measures, transmit
data, exemptions for very small organizations
Healthcare Networks select from defined sets of measures, data
transmission
ORYX® Requirements for Other Accreditation
Programs
ORYX® Requirements for Other Accreditation
Programs Long-term care
Collect and transmit data for 6 measures through a system
share monthly MDS report with surveyor at survey
in 2003 can self-report MDS data to JCAHO
Long-term care Collect and transmit data for 6 measures
through a system share monthly MDS report with surveyor
at survey in 2003 can self-report MDS data to
JCAHO
ORYX® Requirements for Other Accreditation
Programs
ORYX® Requirements for Other Accreditation
Programs Clinical Labs
participate in proficiency testing (CLIA), no data transmission
Ambulatory care no requirements to-date
Clinical Labs participate in proficiency testing (CLIA),
no data transmission
Ambulatory care no requirements to-date
Joint Commission’s Future Plans
Joint Commission’s Future Plans
New Pneumonia Measures Launch of surgical set Critical care measure set followed by other site specific
sets (ED, pain) Disease specific sets Modifications to core measures Sets for other accrediting programs Work with other national organizations (CMS, NQF,
NCQA, etc.)
New Pneumonia Measures Launch of surgical set Critical care measure set followed by other site specific
sets (ED, pain) Disease specific sets Modifications to core measures Sets for other accrediting programs Work with other national organizations (CMS, NQF,
NCQA, etc.)
What hospitals need to do now…..
What hospitals need to do now…..
Begin selecting a performance measurement system
Be aware of the attributes required by JCAHO for systems (at www.JCAHO.org)
Determine internal resources available for data collection, entry and information system support
Begin selecting a performance measurement system
Be aware of the attributes required by JCAHO for systems (at www.JCAHO.org)
Determine internal resources available for data collection, entry and information system support
Objectives Objectives Proactively provide input to JCAHO on the ORYX
core measure project Increase participation in quality of care
improvement activities in Missouri Decrease duplication of performance measurement
activities for hospitals Identify reasonable methods to collect and
transmit core measurement data for ORYX™ compliance
Proactively provide input to JCAHO on the ORYX core measure project
Increase participation in quality of care improvement activities in Missouri
Decrease duplication of performance measurement activities for hospitals
Identify reasonable methods to collect and transmit core measurement data for ORYX™ compliance
Pilot SitesPilot Sites Audrain Medical Center Callaway Community Hospital Cass Medical Center Citizens Memorial Hospital Columbia Regional Hospital Hannibal Regional Hospital Lake Regional Health System Liberty Hospital Nevada Regional Medical
Center North Kansas City Hospital
Audrain Medical Center Callaway Community Hospital Cass Medical Center Citizens Memorial Hospital Columbia Regional Hospital Hannibal Regional Hospital Lake Regional Health System Liberty Hospital Nevada Regional Medical
Center North Kansas City Hospital
Perry County Memorial Hospital
Phelps County Regional Medical Center
Pike County Memorial Hospital
St. Luke’s Hospital St. Luke’s Northland Hospital St. Francis Medical Center St. John’s Mercy Hospital Southeast Missouri Hospital
Perry County Memorial Hospital
Phelps County Regional Medical Center
Pike County Memorial Hospital
St. Luke’s Hospital St. Luke’s Northland Hospital St. Francis Medical Center St. John’s Mercy Hospital Southeast Missouri Hospital
Demographics of Missouri Pilot
Sites
Demographics of Missouri Pilot
Sites 18 acute care hospitals 10 rural, 8 urban Range in bed size from 45 to 493
8 - < 100 beds 3 - 101-200 beds 5 - 201-300 beds 2 - > 300 beds
5 - AMI, 16 - HF, 15 - Pneumonia
18 acute care hospitals 10 rural, 8 urban Range in bed size from 45 to 493
8 - < 100 beds 3 - 101-200 beds 5 - 201-300 beds 2 - > 300 beds
5 - AMI, 16 - HF, 15 - Pneumonia
Pilot Project Hospital Processes
Pilot Project Hospital Processes
Abstracting more than one individual individuals with clinical background risk/quality department provided other support for the project range of 16-60 minutes to abstract per record - decreased with
experience
Data entry 5-30 minutes per record
Integration with information management
Abstracting more than one individual individuals with clinical background risk/quality department provided other support for the project range of 16-60 minutes to abstract per record - decreased with
experience
Data entry 5-30 minutes per record
Integration with information management
Pilot Site Recommendations
Pilot Site Recommendations
Increase education and training on abstraction tools on software on measures
Build up front edits into the software Web-based data entry Web-based, electronic reporting Integration with UB92 hospital systems
Increase education and training on abstraction tools on software on measures
Build up front edits into the software Web-based data entry Web-based, electronic reporting Integration with UB92 hospital systems
The MHA BENCHMARK
Project
The MHA BENCHMARK
Project 1994 - began as MHA membership service Based on UB92 data submitted to HIDI by
hospitals 1997 - became a JCAHO ORYX® performance
measurement system 2000-2001 - participated in ORYX® core
measure pilot project 2002 - enhanced with QualityWorks
1994 - began as MHA membership service Based on UB92 data submitted to HIDI by
hospitals 1997 - became a JCAHO ORYX® performance
measurement system 2000-2001 - participated in ORYX® core
measure pilot project 2002 - enhanced with QualityWorks
Current ProjectCurrent Project MHA membership service
quarterly reports based on UB92 data
ORYX® performance measurement system currently based on UB92 data being enhanced to incorporate core measures developed QualityWorks software
MHA membership service quarterly reports based on UB92 data
ORYX® performance measurement system currently based on UB92 data being enhanced to incorporate core measures developed QualityWorks software
Future PlansFuture Plans Determine need to maintain UB92 based
ORYX® performance measures Determine usefulness of UB92 based
measures to MHA members Determine usefulness of other measure
sets to MHA members
Determine need to maintain UB92 based ORYX® performance measures
Determine usefulness of UB92 based measures to MHA members
Determine usefulness of other measure sets to MHA members
MHA BENCHMARK Project
and QualityWorks
MHA BENCHMARK Project
and QualityWorks ORYX™ core measure system is an enhancement of MHA
BENCHMARK Project QualityWorks Internet-based software Features
On-line data collection, editing, transmission and reporting Collection of data for all core measure sets Specifications provided to integrate data from established hospital
systems Missouri-based customer support and service Standardized clinical reports Consultation available on use of data in qi programs
ORYX™ core measure system is an enhancement of MHA BENCHMARK Project
QualityWorks Internet-based software Features
On-line data collection, editing, transmission and reporting Collection of data for all core measure sets Specifications provided to integrate data from established hospital
systems Missouri-based customer support and service Standardized clinical reports Consultation available on use of data in qi programs
MSC BenefitsMSC Benefits Competitive fee based on licensed beds Fee includes
QualityWorks software training resource manual user conference processing and transmission of data for two core measures sets standardized reports
Experience as a pilot performance measurement system
Competitive fee based on licensed beds Fee includes
QualityWorks software training resource manual user conference processing and transmission of data for two core measures sets standardized reports
Experience as a pilot performance measurement system
Additional Features
Additional Features
Miscellaneous fields for hospital-defined additional data collection
Reporting capability
Miscellaneous fields for hospital-defined additional data collection
Reporting capability
Confidentiality Provisions
Confidentiality Provisions
Password protected data entry Hospital-defined accessibility to
software Encrypted data transmission Contract provisions for MSC to serve as
a business associate
Password protected data entry Hospital-defined accessibility to
software Encrypted data transmission Contract provisions for MSC to serve as
a business associate