The Joint Commission on Accreditation of Healthcare Organizations once again is taking steps toward accrediting healthcare providers based on how well they care for patients.
After more than a decade of hospital industry pressure, endless nit-picking by health services researchers and clinicians, and internal miscues, the JCAHO last week unveiled its latest plan to base accreditation, at least in part, on providers' performance.
But, at least initially, one instance of bad care won't necessarily cause a provider to lose its accreditation.
Since its inception in 1951, the JCAHO has judged hospitals and other providers based on their capacity to provide high-quality care. That capacity so far has been measured by adherence to quality assurance standards largely proved by provider paperwork and on-site reviews by JCAHO surveyors.
Despite the mutual recognition of what it takes to become accredited, the JCAHO and providers alike have implied that accreditation means high-quality performance.
But now that implication appears ready to move toward reality, albeit incrementally.
Christened "Oryx, the next evolution in accreditation," the program will for the first time require healthcare organizations to gather and submit data about the results of care.
(For an explanation of the name, see Outliers, p. 56.)
Initially, Oryx will apply to hospitals and nursing homes. They will have to choose a performance measurement system by the end of this year from a list of 60 approved vendors of clinical information systems. They must start submitting data on two clinical indicators of their choice, covering at least 20% of their patient population, by the first quarter of 1999.
Over several years, the number of indicators and the percent of patients covered in the program will increase.
Health plans, integrated delivery networks and provider-sponsored organizations will participate in a slightly different program. And ambulatory-care, behavioral health, laboratory and home-care organizations will be enlisted in Oryx about a year later.
Hospitals confident of their performance measurement skills can volunteer for the JCAHO's honors program, Oryx Plus. They will use a common set of measures and must commit to disclosing their performance data publicly as early as late 1999.
To explain the program, the Joint Commission is preparing an accreditation manual insert that will be distributed to providers next month.
Hospitals will pay $10 per indicator per quarter to the JCAHO, or a minimum of $80 per year. Start-up costs for hospitals are expected to be around $10,000, with maintenance costs of about $11,000 a year.
"The changes we are talking about *.*.*.*will aggressively change the accreditation process to a data-driven process, more continuous than periodic," said Dennis O'Leary, M.D., Joint Commission president, during a Feb. 18 teleconference broadcast from the JCAHO's Oakbrook Terrace, Ill., headquarters.
O'Leary emphasized that this is just the beginning of a long process. The first objective is "to get everybody on the train." The second goal is to improve the quality of performance.
"We're not going to be able to achieve that on the first day," he said.
The modesty of the goals bespeaks the misfortunes of the project's history. O'Leary has been trying to reach this point since 1986 but has been thwarted by a number of factors.
Soon after O'Leary became JCAHO president in 1986, he announced the "Agenda for Change" program, which was designed to restructure the accreditation process. Most important, accreditation would be based on performance as measured by a common clinical outcome system developed by the JCAHO in conjunction with the hospital industry and organized medicine.
Externally, the hospital industry, led by the American Hospital Association, pressured the JCAHO to drop performance as a basis of accreditation (See chronology). Internally, the JCAHO and panels of experts spent years and millions of dollars debating and testing clinical indicators of quality. But despite the effort, the system didn't help many test hospitals improve care.
Oryx is considerably scaled down from the more grandiose ambitions of 1986 and is a baby-food version of the full-grain performance standards the Joint Commission envisioned.
"I think they're trying to make it easy to get this going," said Jean Chenoweth, vice president of HCIA, a Baltimore-based information systems vendor that has five products on the JCAHO's approved list of clinical outcomes measurement systems. "Over time they will tighten up."
Industry observers and critics noted a number of things absent from or truncated in what O'Leary called "plain vanilla Oryx":
There is no requirement to make performance data public.
Institutions need to submit only two clinical indicators of their choice.
The Joint Commission apparently does not intend to assemble the submissions into one mammoth database that it would control.
There is no ability to compare one specific hospital's outcomes against another specific hospital's. Instead, hospitals compete primarily with themselves, trying to show an upward curve of clinical performance. "Apples-to-apples" comparability will be available, for those who want it, through Oryx Plus.
Hospitals don't have to use the Joint Commission's proprietary clinical indicator system, dubbed the IMSystem. Under the JCAHO's original plan, all accredited hospitals would have been required to use the IMSystem. But under pressure from hospitals, the JCAHO board in January 1995 dropped that requirement and opened up the process to other quality measurement systems.
Most revealing, it appears that accreditation won't be revoked based on unsatisfactory outcomes, at least not at first.
During questioning by reporters last week, O'Leary declined to say specifically whether accreditation would be based on actual patient care. Asked whether there might be a greater percentage of accreditation denials, O'Leary said accreditation will continue to be based on standards, not performance.
"The expectation is that organizations use this data to analyze when they didn't get good results and figure out why. *.*.*.*The issue is how does the organization use the data to improve performance," he said.
O'Leary foresees "great hazards" in using data to grant or deny accreditation. "I don't know any data not subject to multiple interpretations," he said.
The main concept is that clinical performance is supposed to improve over time. Organizations will be "in jeopardy of losing accreditation if they are not able to show that they are using data to drive performance improvement," O'Leary said.
Performance measurements will be collected by hospitals every month and sent to their respective information system vendors. The vendors, in turn, send a report to the JCAHO quarterly in the form of summary data, not patient-specific data.
Because the data can only be understood over time, no institution would lose accreditation based on a single data point.
William Jessee, M.D., vice president for managed care and quality at the American Medical Association and former senior executive at the JCAHO, said the program "will be perceived the way any new Joint Commission standards are: with a certain degree of gnashing of teeth," even though most hospitals are already in compliance with the basic Oryx requirements.
But he said it should get a more favorable reception than the last go-around. "The original idea was a single database. It turned out the world was not ready for that," Jessee said. "They shifted directions with a plan to have a whole variety of databases, essentially letting the marketplace decide which of those are the best and most useful to hospitals. That's probably the most acceptable approach in a pluralistic society."
This insight, however, required a long learning curve on the part of the JCAHO and provoked reams of written commentary. One such article praised this effort with the following: "The most dramatic quality assessment initiative is being undertaken by the Joint Commission on Accreditation of Hospitals under the leadership of Dr. O'Leary. His plan-focusing the hospital accreditation process on clinical performance measures and outcomes-has profound ramifications for hospitals and physicians."
Those words appeared in a glowing profile of O'Leary in the Feb. 27, 1987, issue of MODERN HEALTHCARE.
Why has it taken 10 years to reach this point?
"Ten years and no small number of feet marks in my back," O'Leary replied. "Some felt we were moving too fast, some felt we were moving too slowly. Nobody felt we were moving on time. Let's be honest. People don't like to be measured. That is part of the human condition. We have run into resistance in various forms to reach the point we reach today. I don't feel bad about it. I feel pretty good we got to this point in 10 years."