Last month's decision by the Joint Commission to revise its performance measurement requirements for its Oryx accreditation program came as welcome relief at Excelsior Springs (Mo.) Medical Center.
"Wonderful," said hospital Chief Executive Officer Sally Nance when told of the 60-day delay in imposing the standards. "I think that will affect us. It makes sense."
Like many managers of small hospitals, Nance and her team have been paddling hard to join the mainstream of performance measurement as spelled out by the Oakbrook Terrace, Ill.-based Joint Commission on Accreditation of Healthcare Organizations.
In February 1997 the Joint Commission unveiled Oryx, its latest attempt to accredit hospitals and other institutional providers based, at least in part, on how well they care for patients. The Oryx program requires healthcare organizations to select their own clinical indicators and choose the software vendor to submit their outcomes reports to the JCAHO (Feb. 24, 1997, p. 2).
Hospitals must start collecting data by the third quarter of this year and submit it to the commission by the first quarter of 1999.
To meet those deadlines, healthcare organizations originally had to select their clinical indicators and vendors by Dec. 31. But roughly a month ago, the executive committee of the JCAHO board extended the cutoff point to March 2 and eased some of the reporting rules.
The Joint Commission capped at five the number of clinical measurements providers have to submit to reach the threshold of 20% of patient discharges. It also eased requirements for adding new indicators in future years (Dec. 15, 1997, p. 16).
All together, those changes amount to a breather for hospitals and nursing homes large and small that haven't figured out all the angles on Oryx.
"The midsize on down, especially the smaller hospitals, are going to have the most difficulty," said Ken Smithmier, president and CEO of 247-bed Decatur (Ill.) Memorial Hospital. "They don't have the staff or the systems you need to pull some of this stuff off."
Smithmier applauded the Joint Commission for extending its deadline and relaxing its rules. People are now focused on Oryx but need extra time to figure it out, he said. "Otherwise, you run the risk of people just slapping things together to satisfy some arbitrary deadline without meaningful data."
Meaningful data are exactly what Nance and Excelsior Springs are trying to extract from this exercise.
"We want to target on those areas we feel will be most beneficial for our patients," she said. "The hard part is coming up with quality indicators that work best for us and the Joint Commission."
Excelsior Springs has a typical profile for a rural hospital close to a metropolitan area. Nestled in a hollow 30 miles northeast of Kansas City, Mo., the town's hospital is licensed for 129 total beds: 49 acute care, 60 skilled nursing and 20 residential care. It runs 100% occupancy on residential care and almost that on skilled nursing.
But the acute-care census can fluctuate from 18 one day to six the next. It averages less than 10, meaning the hospital doesn't have to submit Oryx data for acute care.
"We don't do hearts, we don't do brains, we don't do babies any more," Nance said. Those go 20 miles down the road to Liberty (Mo.) Hospital or to North Kansas City (Mo.) Hospital.
"But on the ambulatory-care side, you have to have over 300 contacts a month," Nance said. "We have 325. We're just right over." So Excelsior Springs will compile Oryx data for ambulatory care, long-term care and home health.
Ambulatory care is proving trickier than expected. Nance hasn't found a vendor she likes. The Missouri Hospital Association has certain indicators approved for Oryx use by the Joint Commission, but the clinical areas Excelsior Springs wants to work on aren't among them.
"At first we thought our issues were technical: How do we download and transmit data? Do we have the staff?" Nance recalled. "But then the real problems turned out to be finding the vendors."
Right off the bat, Excelsior Springs started looking for vendors as soon as Oryx was announced last February. Many vendors didn't have their software and their indicators ready, so the hospital couldn't analyze the system or the cost. Cost is a big issue for hospitals of this size.
At the end of December 205, software vendors had been approved for Oryx submission. The JCAHO isn't keeping tabs on how many hospitals have notified it of their vendors and indicators.
Most vendors offer things the big hospitals want to report, Nance explained: trauma, obstetrics, cardiac indicators. "Everyone has those. When you're a small hospital, you're not doing a lot of trauma. And the rural hospitals are not doing a lot of (obstetrics), especially if they're close to a metropolitan area." Thus, it's very hard for Excelsior Springs to hit the 20% threshold of patient discharges using just a few measures. The cap of five will help a great deal.
Nance estimates that complying with Oryx will cost her hospital about $20,000 next year. That includes the software, additional computer hardware and the Joint Commission's fee. That doesn't include additional staffing or working hours, the cost of which can't be assessed yet.
Excelsior Springs is thinking about using infection control and medication use as clinical indicators in long-term care. The thing is, the hospital is doing well on infection control already, according to benchmark comparative data. "To show improvement will be very difficult," Nance said.
Skin ulcers might appear to be another obvious candidate, but Nance said that's not true. "We do a good job with (skin ulcers). It's difficult to show improvement. If it's something you've monitored in the past and you've done a lot of work in that area, it wouldn't be a worthwhile indicator for the Joint Commission.
"You want to say, here's an area we've identified where we should improve," she added. "If we go through the quality-improvement process, we should be able to show improvement to the Joint Commission, and they'll say, `Yes, we're complying with that standard.' "
Excelsior Springs has a longstanding partnership with nearby North Kansas City Hospital for technical support and medical referrals, but that's not helping much this time. The types of clinical measurements that Oryx requires are such a far cry from what's expected of the big hospital, this time the little hospital must wing it solo.