Hospitals to Gather and Use Additional Performance Data in 2004

OAKBROOK, Ill. -- Expanded Joint Commission

performance measurement expectations will require accredited hospitals to

begin gathering and using data on an additional set of core performance

measures beginning in January 2004.

The new requirement, approved last month by the Board of Commissioners of

the Joint Commission on Accreditation of Healthcare Organizations (JCAHO),

will increase the scope of hospital collection and reporting of

performance measure data from two to three sets of core measures.

Hospitals can at present choose from four core measure sets that address

acute myocardial infarction, heart failure, community acquired pneumonia,

and pregnancy and related conditions.

"By focusing measurement efforts on the most common inpatient conditions,

hospital data-driven improvement efforts will have the broadest possible

impacts," says Dennis S. O'Leary, MD, president of JCAHO. "These are also

clinical conditions that are of great interest to a variety of regulatory,

purchaser, and consumer groups."

Core measures are part of the Joint Commission's ORYX initiative whose

principal objective is to integrate outcomes and other performance

measurement data into the accreditation process. The goal is to create a

continuous, data-driven accreditation process that focuses on the actual

results of care.

In addition to the current core measures, the Joint Commission is actively

developing new measure sets that address surgical infection prevention,

ICU care, pain management and inpatient pediatric asthma. These measure

sets are expected to become available incrementally over the next six to

24 months.

An initial group of 10 core measures -- derived from three of the Joint

Commission's current ORYX core measure sets -- has been identified for

voluntary public reporting by The Quality Initiative: A Public Resource on

Hospital Performance. The Quality Initiative is being led by the American

Hospital Association, the Federation of American Hospitals, and the

Association of American Medical Colleges, and supported by the Joint

Commission and the Centers for Medicare and Medicaid Services, among

others. This initiative marks an important milestone in efforts to provide

the public with useful, understandable quality information regarding

patient care and outcomes in individual hospitals.

Increasing the core measurement requirement from two to three measure sets

will now allow accredited hospitals to use ORYX core measure selections

both to satisfy Joint Commission requirements and to fully participate in

The Quality Initiative in a coordinated manner.

The new requirements continue to provide alternatives for the relatively

small number of hospitals to whom the current core measure sets do not

apply. Most of these are specialty (e.g., pediatric, psychiatric)

hospitals. Data gathering and reporting requirements for these hospitals

will also increase modestly beginning in 2004, as follows:

- Hospitals currently reporting data on one core measure set and three

non-core measures will report data on one core measure set and six

non-core measures.

- Hospitals currently reporting data on six non-core measures will report

data on nine non-core measures.

- Hospitals currently reporting data on two core-measure sets, but unable

to identify a third core measure set, will report data on two core measure

sets and three non-core measures.

For more information about the Joint Commission's ORYX and core measure

requirements, go to the Joint Commission's website at

www.jcaho.org.