The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently announced Oryx, a quality improvement initiative that reflects the increasing use and importance of performance measures in U.S. medical practice. By December 31, 1997, accredited hospitals and long term care organizations will be required to select from a group of JCAHO-approved vendors two or more clinical performance measures that relate to at least 20 percent of their patient populations. The selected vendor will then have a year to begin submitting data to JCAHO on the institution's behalf. Ultimately, summary performance data from one institution will be compared to its own data, and to data from other organizations that use the same measures.
 
Similar requirements will apply to health networks, laboratories and outpatient facilities seeking JCAHO accreditation, and the Commission anticipates everyone's involvement will increase as the Oryx initiative takes hold.
 
JCAHO is also encouraging accredited hospitals to participate in Oryx Plus, an expanded national database that will permit benchmarking and performance comparisons. For this option, the Commission says, hospitals will use a common set of acute care measures, and will have to commit themselves to public disclosure of "meaningful" performance data and information. Participating institutions will receive recognition and should be able to remain with their performance measurements systems provided they add the common measures for Oryx Plus.
 
The success of this degree of data-collection and statistical analysis is possible only through the extensive use of computers for recording and manipulating patient data, and the adoption of standards for medical data is a necessary prerequisite if the resulting performance measures are to have any chance at being comparable at a national level.
 
For more information on Oryx, ask your institution's QA director, call the JCAHO's Oryx information line at 630-792-5085, or visit the JCAHO Web site.

 
How is JCAHO's Oryx initiative likely to affect U.S. medical institutions and their physicians? Responses were solicited from a Joint Commission representative, a health network information systems executive, and two physicians:

Use of data is the main point: providers and clinicians should be looking at their data to determine if additional action is needed to investigate the issue, and then to take action to improve. Hopefully, it will have different clinicians and departments working together to improve care.
 
--- Deborah Nadzam, PhD, RN, vice president, Performance Measurement, JCAHO
 
 
It's about time. It's about time that JCAHO found a way to transcend the politics of developing reportable measures for determining quality. It's about time that they have taken a stab at developing universal and measurable definitions for quality. Where it falls short, however, is the number of measures and the roll-out schedule. Many organizations, local cooperatives and national organizations have already developed quality measures that are of questionable validity and usefulness and only serve to confuse in the public's eye the meaning of quality and the commitment of health care in general to the reporting it needs. My only hope is that the Joint Commission accelerates its roll-out plans and moves aggressively into this area.
 
We are developing in any case, as part of our clinical systems installation initiatives, a comprehensive data dictionary that defines each of our data elements and the way in which they are captured and normalized. The JCAHO Oryx effort and the leadership position being assumed by the Commission will give us an external standard against which to benchmark our efforts and provide guidance for problematic elements and expressions of "quality."
 
What does this mean for my clinicians? This is perhaps the most problematic element of the roll-out of Oryx. Medical staff, who will be measured and who will use these data, will need to develop consensus on the definition of the elements and the standards to be measured. If JCAHO is vague in the definitions of elements and cannot provide guidance in their collection and evaluation -- as they were the last time they attempted to develop automated tools for quality reporting, credibility will be lost and the development of the standard quality reporting tool will be hampered.
 
---George S Conklin, Vice President of Information Systems and Chief Information Officer, Integris Health
 
 
I spent some time looking into the Oryx initiative and discussed it with our hospital's quality director. Her opinion is that it is primarily a political move. It certainly will be job security for her line of work.
 
We are already planning two programs that happened to already be on the sanctioned list so it actually will make no practical difference at first. I expect that when the comparisons start to be published that there will be a lot of maneuvering to spin the results. The emphasis on using data sounds good but much of the time statistics are used that may or may not have clinical significance even though they may have "statistical significance". I hope we can get the focus on clinically significant outcome statistics and not process-type stuff. I'm not holding my breath.
 
---Mark E Spencer, MD, Medical Director, Snohomish County Physicians Corporation, a Division of King County Medical Blue Shield.
 
 
I am concerned Oryx Plus statistics will result, not in improved care, but in improved ways to spin the data. Publicizing performance measures is laudable in theory but likely to be very misleading in practice.
 
JCAHO describes the goals of Oryx in its Dear Colleague letter of February 21, 1997: "The Oryx initiative is intended to be a flexible and affordable approach to progressively increasing the relevance of accreditation, and an important building block for supporting quality improvement efforts in accredited organizations." Medical QA/CQI is a statistical and problem-solving activity designed to quantitatively monitor, and improve the quality of, delivered care on an ongoing basis. Since true facts and honest statistics can only be collected in an atmosphere free from fear of retribution or negative consequence, by classic definition QA must never become public for benchmarking, comparisons, or any other purpose. But JCAHO's statement on the Oryx initiative makes it clear its quality improvement effort is for organizations to "...have objective, quantifiable information about their own performance which they can use externally to demonstrate accountability. The Oryx initiative will help organizations meet this need...." Performance measures are sometimes used by individuals and institutions to quantitate the quality of care provided -- a process which when made public or used punitively is, to me, no longer QA.
 
Institutional accountability to both accreditation organizations and the public is a critical check-and-balance, and how to best accomplish this remains the subject of much debate. But, irrespective of philosophy or management style, I hope institutions deliberately separate their private ongoing quality improvement program from their public performance measurements. Can Oryx help actualize the laudable goals of medical QA/CQI by encouraging the honest collection of clinically significant, unbiased performance measures if, at the same time, JCAHO is using Oryx to encourage the equally laudable goal of constructive and cooperative sharing of these performance measures as a reliable benchmark upon which to compare healthcare activity? It will be interesting to see if Oryx or Oryx Plus can accomplish either, much less both, of these objectives.
 
---Marjorie Lazoff, MD, emergency physician
 
 

For further information: Fortunately, the full text version of The New England Journal of Medicine's six part series on Quality of Care is on line, beginning with the introductory article from Sept 19, 1996. See the bottom of that page for all sections of Part I, then navigate through the rest of the series by returning to that issue's Table of Contents and advancing one by one through the next five issues.
 
Two articles within the series are particularly germane to the Views discussion: Skepticism about Quality Improvement, which addresses the mistrust physicians have for QA programs in general, and The Role of Physicians in the Future of Quality Management, which talks more specifically about report cards and HEDIS. Other NEJM articles of interest include several Letters to the Editor and their replies, which articulate common controversial issues evoked by the series. Also, an editorial refers to the other major U.S. health facility accrediting organization, the National Committee for Quality Assurance.
 
 

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