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January 28, 2002

JCAHO’S BIG DIG:
EMBEDDING STANDARDIZED CORE MEASURES
By Linda K. Weeks, MBA, MS, RHIA

The role of HIM and health information services in implementing and supporting core measures varies according to the size, type, and organization of accredited programs and facilities. Core measures require data collection that is documentation-oriented and medical record-based even when data collection is concurrent to point of service and point of care. Practice domains and practice competencies are updated to include core measures.

The Web site for the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) provides an extensive selection of materials on performance measures and core measures. Online offerings are exceptional references and resources for general information, frequently asked questions, and detailed support data and information. An abstract of these online offerings is presented as the condensed guide to the basic essentials of core measures. (For further details, please review these references and resources online at www.jcaho.com.)

Overview of Oryx
Oryx, the JCAHO initiative implemented in 1997 to integrate performance measures into the accreditation process, is now a familiar name to all. Performance measures complement the standards-based process. Oryx is a data-based, continuous survey process presenting outcome-based data. Outcomes are introduced into the accreditation process to improve outcome of care and services.

The Oryx initiatives cover accreditation programs in hospitals, long-term care, healthcare networks, laboratories, home care, and behavioral healthcare services. Newly accredited organizations select performance measures from a universe of relevant measures. Performance measures for the various types of facilities were phased in over a two-year period as the selections became available. These familiar Oryx performance measures are being built upon as standardized core measures. Core measures, which are being embedded into the accreditation process as critical elements of compliance, benchmark process and actual outcome of patient care and service.

Migration to Core Measures
The core measures selected in 1999 are detailed in definition and uniformly embedded into multiple performance measurement systems. All data collection protocols are standardized in common, uniform medical language. Their criteria for evaluation are standardized across facilities. As with the performance measures, the core measures are scheduled for progressive introduction by accreditation program type after completion of significant pilot studies. The standardization and uniformity of the core measures is designed to provide comparison of performance against other accredited program participants and aggregate national benchmarks. Core measures reiterate the process established by the state hospital association’s Core Measure Implementation Task Force.

Five focus areas (FA) are currently under pilot testing in more than 80 hospitals in Connecticut, Georgia, Michigan, Missouri, Rhode Island, South Carolina, Virginia, and Texas. The pilot testing includes the measure sets for acute myocardial infarction, heart failure, and pneumonia. The final FA are for acute myocardial infarction and coronary artery disease, community-acquired pneumonia, heart failure, pregnancy and related conditions, and surgical procedures and complications. The migration to core measures begins July 1 for hospitals. An annual participation fee and transmission fees are assessed for each organization.

Core Measure Development
Selection of the Advisory Council on Performance Measurement began with nominations for four advisory panels with acute myocardial infarction and heart failure combined into one panel. Core panel members were eventually selected from more than 400 nominations. Panels determined clinical logic, scope of initial measure set, and initial measures comprising sets.

The JCAHO Advisory Council on Performance Measurement evaluated the measurement sets. The criteria for evaluation are the Attributes of Conformance, which are performance measures, technical capabilities, data quality, risk adjustment and stratification, performance measure-related feedback, relevance for accreditation, and technical reporting requirements. A series of measurable components is sequenced for each attribute.

Initial core measure set selection was performed by consensus of the advisory panel members and by extensive preference and priority input from interested parties, including hospitals, purchasers, consumer groups, performance measurement systems, state medical societies, and professional organizations. The advisory panels designed core measure sets with the intent of a robust picture of care provided in a given FA. Additional core measure sets are being developed. Core measures for both care provided and other services are included in the expanded efforts.

During 2000, the initial measure sets that became available included profiles for measure names, numerator population, and denominator population to accredited hospitals and measurement systems. Beginning in 2001, the five state hospital associations began pilot testing. These provide an opportunity for early experiences in implementing the core measures, including the technical embedment into performance measurement systems. Pilot sites are able to establish cost data regarding technical applications and specifications and are identifying training, staffing, and collection requirements. Data quality is also being tested during this pilot phase. Upon completion of the pilot, the core measures are subject to modification and revision.

Selections and Changes
Participation in the performance measures and core measures is mandatory. Failure to enroll and to select performance measures required results in a special Type 1 recommendation. Any further extension in enrollment or selection after receipt of a special recommendation can potentially contribute to loss of accreditation.

Performance measures allow for a change in selection after 12 consecutive submissions. Any changes must meet the requirements and specifications for time, date, reason, and authorization. The rule on 12 consecutive submissions also applies to self-reported measures. This change of procedure requires notifying JCAHO, completing the online form for change, and maintaining the documentation for on-site survey review.

Each accredited organization has a JCAHO account representative who assists with questions about changes in measurement systems. These representatives also address any other concerns or issues related to the accreditation process or accreditation maintenance for the organization.

Six performance measures continue to be required of hospitals, long-term care, home care, and behavioral healthcare services until the implementation of core measures for each accreditation program. Organizations continue to have the option of collecting more than six performance measures. Surveys prior to core measure implementation continue to score selection of performance measures and utilization in improving organizational performance activities. The organization is scored on its ability to collect reliable data, conduct credible analysis of data, and initiate process improvements.

Clinical Measures and Patient Perception of Care Measures Clinical measures evaluate the process and outcome of clinical services delivery. These relate to appropriateness of clinical decision making and implementation of clinical decisions. Clinical measures are specific to condition, procedure, or patient care function. It is possible that a clinical measure is classifiable to more than one category. Patient perception of care measures are satisfaction measures for delivery of clinical care. These measures are evaluated from the point of view of the patient, family, or caregiver. Patient perception of care measures are specific to aspects of the delivery of clinical care. It is also possible that a patient perception of care measure is classifiable to more than one category.

A measurement mix of both clinical measures and patient perception of care measures is acceptable. During a survey, all data collected for organizational improvement of performance are reviewed even if they are not submitted under performance measurement. Under the current performance measurement system, organizations are compared only with others using the same system and same measures. Currently, differences are identifiable through data dictionary maintenance. With the implementation of the core measures, organizations are to have standardized core measures within an accreditation program with comparisons across all organizations within the category of accreditation.

Data Collection, Submission, and Assessment
Organizations collect data monthly with quarterly data transmitted to JCAHO by the measurement system. Any self-reporting performance measures are collected monthly by the organization. Aggregate data are maintained for self-reporting performance measures by the organization for review during an on-site JCAHO survey.

Monthly data collection provides adequate data points to permit aggregate charting as a continuous process. Currently, statistically sound population sampling is acceptable in meeting compliance with the standard. Without a valid sample population, generalization of results is not accurate enough for reporting. Each approved measurement system is required to follow JCAHO guidelines for statistically sound population sampling. Measurement systems may apply risk adjustments to performance measures. Risk adjustment employs a statistical process for reduction and clarification of multiple confounding factors differing among comparison groups—a simplified form of risk adjustment is stratification. The application of stratification classifies data by characteristics, variables, and categories. JCAHO sends error reports on aggregate data submitted incorrectly.

Scoring during surveys evaluates the application of process analysis to the findings. Surveyors have summaries of statistical outliers, control charts, and comparison charts. A summary of performance measures is detailed for the surveyor prior to an on-site visit. Surveyors follow standardized protocols for interpreting control and comparison charts. Protocols and interview questions are provided by JCAHO. Each organization receives a presurvey report on performance measures. The interview questions begin with the rationale for the selection of performance measures, integration of performance measures into improving organizational performance activities, and outcomes of activities. Additional attention during the performance measure interview is focused on leadership and management of information integration.

Initial Core Measures Participation Requirements: Acute Care Hospitals Noncore measure sets are eliminated for those small hospitals demonstrating presence of the core measures. Two of the initial five measures are required by June 2002. Selects are to be correlations with high-risk, high-volume, and problem-prone areas. From July, hospitals are required to collect data on all applicable core measures and noncore measure requirements terminate. Hospitals with only one identifiable core measure set reduce noncore measures from six to four upon notification to JCAHO. If a hospital cannot identify any core measure sets, it continues with the six noncore measure sets.

JCAHO projects a six-month notification prior to any changes in its core measure sets. A commitment is in place to modify or rotate core measure sets infrequently and only upon necessity. Data collection requirements begin six months after announcement of modified or rotated core measures. Rotation is requested whenever the hospital or JCAHO believe usefulness is diminished by attained and sustained compliance with exemplary performance with minimal variance over defined periods. The core measure sets are available in detail on the JCAHO Web site. A brief description of each core performance measure, including deferred and delayed core measures, follows. Each core measure is provided with attributes and associated evaluation criteria. A brief description of each attribute and its criterion are included following the core measure briefs.

First Complement of Performance Measures: Acute Care Hospitals
Acute Myocardial Infarction (AMI)
• AM 71 Reperfusion Therapy — Time from Arrival to Initiation: timely reperfusion (opening blocked arteries) of eligible AMI patients; time from arrival to initiation of thrombolysis medication administration
• AM 7b Reperfusion Therapy — Time from Arrival to Initiation: timely reperfusion (opening blocked arteries) of eligible AMI patients; time from arrival to initiation of primary percutaneous transluminal coronary angioplasty
• AM 14 Smoking Cessation Advice/Counseling — AMI patients with a history of smoking who are given smoking cessation advice or counseling during hospitalization
• AM 21 Aspirin at Arrival — AMI patients who are given aspirin within 24 hours of arrival or within 24 hours prior to arrival to the hospital
• AM 27 Aspirin at Discharge — AMI patients who are prescribed aspirin at discharge from the hospital
• AM 35 left ventricular ejection fraction (LVEF) < 40% Prescribed angiotensin converting enzyme inhibitor (ACEI) at Discharge — AMI patients with low LVEF (index of how well the heart functions) who are prescribed an ACEI at discharge from the hospital
• AM 37 Beta Blocker at Discharge — AMI patients who are ideal candidates for beta blocker medication who are given a prescription for beta blockers at discharge
• AM 46 Inpatient Mortality — patients with a primary diagnosis of AMI who expire during hospitalization
• AM 47 Beta Blocker at Arrival — AMI patients who receive beta blocker medication within the first 24 hours of arrival to the hospital

Heart Failure
• HF 36 Diet/Weight/Medication Management Instructions at Discharge — heart failure patients who receive patient education (as documented on their written discharge instructions) regarding all of the following:
all discharge medications, weight monitoring, diet, activity level, follow-up appointment, what to do if symptoms worsen
• HF 38 Assessment of Left Ventricular Function — heart failure patients not admitted on ACEIs or angiotensin receptor blocking agents who have LVEF evaluated before or during admission
• HF 44 < 40% Prescribed ACEI at Discharge — patients with low LVEF who are prescribed an ACEI at discharge
• HF 45 Smoking Cessation Advice/Counseling — heart failure patients with a history of smoking who are given smoking cessation advice or counseling during hospitalization

Deferred
• HF 10 Patients with Atrial Fibrillation Prescribed Warfarin at Discharge — heart failure patients with atrial fibrillation (irregular heartbeat) who are given a prescription for oral anticoagulation therapy (warfarin) at discharge from the hospital

Community-Acquired Pneumonia
• PN 18 Oxygenation Assessment — patients who receive oxygenation assessment (determine amount of oxygen in blood) within 24 hours of hospital arrival
• PN 19 Pneumonia Screen or Pneumococcal Vaccination — patients aged 65 or older who are screened for or given pneumococcal vaccination during hospitalization
• PN 21 Blood Cultures — patients who have blood cultures collected and had them drawn prior to first dose of antibiotic administration in the hospital
• PN 24 Antibiotic Timing — time in hours from initial presentation at hospital to first dose of antibiotics
• PN 30a Smoking Cessation Advice/Counseling — adult pneumonia patients with a history of smoking who are given smoking cessation advice or counseling during hospitalization
• PN 30b Smoking Cessation Advice/Counseling — pediatric pneumonia patients with a history of smoking who are given smoking cessation advice or counseling during hospitalization, or advice or counseling is given to pediatric caregiver about effects of secondhand smoke Pending Implementation
• PN 22 Empiric Antibiotic Regimen Non-ICU — for pneumonia patients not admitted to an intensive care unit, the antibiotic given is consistent with current consensus guidelines

Pregnancy and Related Conditions
• PR 14 VBAC Rate — patients who have had a cesarean section who then have a vaginal delivery
• PR 19 Neonatal Mortality — infants who expire within 28 days of birth
• PR 25 Third or Fourth Degree Laceration — patients who have vaginal deliveries with third or fourth degree laceration

Surgical Procedures and Complications Potential Delayed Implementation
• SG 17 Surgical Site Infection within 30 days for selected procedures — patients undergoing selected surgical procedures who develop a surgical site infection within 30 days of the procedure
• SG 45 Timing of Prophylactic Administration of Antibiotic — timing of when patients were given prophylactic intravenous antibiotic administration for selected surgical procedures

Attributes and Evaluation Criteria
Attribute A targets improvements in healthcare populations. Criteria include measurement of explicit rationale consistent with protecting and improving health and care; addressing high risk, high volume, problem prone, inappropriate variation; addressing factors applicable to disease prevention, screening, diagnosis, and management; and addressing needs of populations with diverse healthcare requirements.

Attribute B defines and specifies the extent to which measures are standardized for data collection and calculation of values and scores. Criteria include numerator, denominator-type measurements; rule identifying targeted populations; defined data elements, data sources, allowable values; defined sampling procedures; algorithm for calculating values and scores; and defined risk adjustments.

Attribute C defines reliability of design, application across organizations, and time. Criteria include demonstration of minimal random error and reproduction capability including description of data quality evaluation process, documentation of results, and description of evaluation process.

Attribute D defines data capture. Criteria include description of validity evaluation process, documentation of test results, and documentation of construct support.

Attribute E interprets improvement of health. Criteria include demonstrating variance and report capability.

Attribute F addresses adjustment and stratification of influencing factors. Criteria include documentation of approach used, description of clinical rationale and statistical processes, description and definition of risk adjustment model validation results, and description of process for strata.

Attribute G assesses data elements, abstracting, and collection. Criteria include demonstrating data collection process for data elements, data sources, data sample, data system, and data costs. Attribute H identifies usefulness to the accreditation process in general and improving organizational performance in particular. Criteria include monitoring between surveys, identifying interventions between surveys, providing focused, on-site surveys, and supporting overall benchmarking and best practice.

Attribute I indicates provider control. Criteria include addressing provider influence, control, and ability to effect change in outcomes. Attribute J prescribes public availability and access of the measure construct and calculation algorithm for public use. Criteria include the construct and calculation algorithm in the public domain or availability without royalty.

Core measures are the next natural step in the migration to interactive benchmarking of performance measures embedded in the accreditation process itself. Benchmarking across the spectrum of accredited facilities offers exceptional opportunity for enhancing the aggregate data process and for improving the perception of its usefulness to accredited organizations.

For those accredited programs other than acute care hospitals, activities are already underway through private initiatives to benchmark and share comparative data within related or corporate systems. Setting your own benchmarks in limited networks prepares the organization for the upcoming inclusion of benchmarking performance measures.

The role of HIM and health information services in implementing and supporting core measures is going to be different for each accredited program and individual facilities. The core measures, however, will be standardized. The medical record and health information services come to the foreground again as a resource and provider of data and information for improving organizational performance. It is timely to now update practice domains and practice competencies for core measures. — Linda K. Weeks, MBA, MS, RHIA, is an independent contractor.

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