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Joint Commission’s role in internal quality data

Quality improvement

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  • Discuss The Joint Commission and quality data collection

In a world where consumers can collect encyclopedic knowledge on a car or home electronics purchase, the need for usable, measurable quality data grows every day, particularly in healthcare.

More regulatory and other organizations are focusing on quality data collection, Stephanie Iorio, RN, CPHQ, CPC, said during her presentation, “The Im-pact of Quality Data on the External Environment,” given at September’s National Association for Healthcare Quality conference, which was held in Grape- vine, TX.

Current themes in quality measurement include an absence of standardization of measures and data element definitions, a need to harmonize measures across healthcare settings, a growing demand for measures of efficiency, and use of administrative and other electronic data. There has also been a movement toward “episodes of care,” Iorio said.

Other themes that are currently hot in quality measurement include:

  • Measuring the quality of data, particularly data that are self-reported
  • Pay for reporting and pay for performance
  • Process versus outcomes measures
  • Patient privacy and confidentiality
  • The growing role of consumers

“Are we measuring the right processes?” said Iorio. There are more than half a dozen regulatory or reporting agencies that are tracking quality data in the acute care setting—not just CMS and The Joint Commission, but also such staples as the National Quality Forum, the Agency for Healthcare Research and Quality, the Institute for Healthcare Improvement, Leapfrog, and HealthGrades. But despite this, “today you can find out more about a TV you want to purchase than about your own healthcare online,” said Iorio.

The crux of quality is data, she said. Data analysis reveals a great deal about quality and patient safety. Reviewing data can show trends in appropriateness of care, variations in practice and outcomes, and resource utilization. Movement away from manual chart reviews, which are time- and resource-intensive, to the electronic record has revolutionized the availability and usefulness of administrative data, Iorio noted.

The Joint Commission

So where does The Joint Commission play into all this? This year, ORYX reporting required four measure sets. Additional measure sets are in development, and measures are being reworked for capture through the electronic health record system. Also beginning this year, The Joint Commission considered introducing paired mandatory reporting requirements—that is, certain measures that would be tied together in required reporting. For example, if your facility reports cardiac care measures, either myocardial infarction or heart failure measures would also be required. Similarly, surgical services measures would mean Surgical Care Improvement Project infections would also need to be reported.

Most hospitals would meet the remainder of reporting requirements by choosing to report some combination of nursing-sensitive, pneumonia, children’s asthma care, and pregnancy measures, said Iorio.

Iorio pointed out the law of diminishing returns here: “If you’ve been reporting on the same measures [for some time], how many times can you do so before you max out on your potential?” she said.


Adapted from Briefings on The Joint Commission, November 2009, HCPro, Inc.

What is ORYX?

ORYX measurement requirements are intended to support Joint Commission–accredited organizations in their quality improvement efforts. Performance measures supplement and help guide the standards-based survey process by:

  • Providing a more targeted basis for the regular accreditation survey
  • Continuously monitoring actual performance
  • Guiding and stimulating continuous improvement in healthcare organizations

Some accredited organizations are required to submit performance measurement data on a specified minimum number of measure sets or noncore measures, as appropriate, to The Joint Commission through a Joint Commission–listed ORYX vendor (also known as performance measurement systems). Data collected or submitted to The Joint Commission are reviewed during the on-site survey.

Current measure sets

How do the existing measure sets stack up? The following indicates how existing measure sets are looked at currently, as well as when upcoming changes are expected to be implemented.

Venous thromboembolism (VTE) measures

  • Joint Commission only
  • Implemented with October 2009 discharges
  • Applicable to all inpatient discharges, including minors without VTE, with Princ Dx VTE, and with other Dx VTE

Perinatal care measures

  • Joint Commission only
  • Expected implementation date: April 2010 discharges
  • Endorsed by the National Quality Foundation—based on current scientific evidence
  • Looks at domains of care: assessment and screening, prematurity, infant feeding, and continuity and transition

Stroke measures

  • Joint Commission only
  • Implemented with October 2009 discharges
  • Applicable to all stroke patients but required by primary stroke centers
  • Includes ischemic and hemorrhagic strokes

ED measures

  • Joint Commission and CMS consider these measures informational
  • An implementation date has not yet been established
  • Looks at the following ED concepts: patient wait time, overcrowding, boarding, and diversions

Nursing-sensitive measures

  • Joint Commission only
  • Expected implementation date: April 2010 discharges
  • Looks at multiple data sources: clinical abstraction, event reporting, administrative, workforce, and surveys