Vermont Hospital Association and MHA Management Services Corporation

1. Vermont Hospital Association and MHA Management Services Corporation May 2, 2002

2. 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

3. The Joint Commission�s Perspective

4. 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

5. 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

6. 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. History of JCAHO Performance Measurement

8. 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

9. 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

10. A 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

11. Status of ORYX� Systems(as of January 2002) Total listed systems = 186 Total possible new systems = 30 Total systems withdrawn since beginning of ORYX� initiative = 155 Total systems that have signed an agreement for core measures = 40

12. 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)

13. 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

14. ORYX� Core Measure Pilot Project

15. 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)

16. Pilot Measure Sets Congestive heart failure Acute myocardial infarction Pneumonia

17. 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

18. 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

19. ORYX� Core MeasuresImplementation

20. ORYX� 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 HF discharge instructions LVF assessment ACEI for LVSD smoking cessation advice

21. ORYX� Core Measure Sets 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. Sampling 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

28. Risk 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

29. Reporting Required Control charts Comparison charts Additional reports possible

30. 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

31. 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

32. ORYX� Requirements for Other Accreditation Programs Clinical Labs participate in proficiency testing (CLIA), no data transmission Ambulatory care no requirements to-date

33. 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.)

34. 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

35. Missouri�s Pilot Project

36. 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

37. Pilot 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 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

38. 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

39. 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

40. 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

41. Missouri ORYX� Core Measure Pilot Site Panel

42. The MHA BENCHMARK Project and QualityWorks

43. 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

44. Current 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

45. Future 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

46. 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

47. MSC 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

48. Additional Features Miscellaneous fields for hospital-defined additional data collection Reporting capability

49. Confidentiality Provisions Password protected data entry Hospital-defined accessibility to software Encrypted data transmission Contract provisions for MSC to serve as a business associate

50. QualityWorks