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

The Joint Commission’s Perspective

The Joint Commission’s Perspective

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

History of JCAHO Performance Measurement

History of JCAHO Performance Measurement

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

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 Measures

Implementation

ORYX® Core Measures

Implementation

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

Missouri’s Pilot Project

Missouri’s Pilot Project

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

Missouri ORYX® Core Measure Pilot

Site Panel

Missouri ORYX® Core Measure Pilot

Site Panel

The MHA BENCHMARK Project

and QualityWorks

The MHA BENCHMARK Project

and QualityWorks

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

QualityWorksQualityWorks