Enterprise Software

Implement a performance measurement system to comply with JCAHO

A component of the Joint Commission on Accreditation of Healthcare Organizations requires hospitals to collect discharge information on specific groups of patients. Here's a look at JCAHO's performance measurement requirements.

Healthcare organizations throughout the United States require licenses or certifications from state and federal agencies. These certifications are typically the result of unannounced site visits by an inspector whose objective is to ensure that the organization is complying with minimal standards as outlined in applicable regulatory guidelines. The results of such inspections can range from certification to sanctions, fines, or even closure.

A "minimal compliance" certification is hardly a quality recommendation for an institution. Fortunately, healthcare accreditation organizations, which focus on quality measurement and improvement, help fill this void. One such organization is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Tracing its roots to the early 1950s, JCAHO has matured into the leading provider of healthcare enterprise accreditation in the United States.

JCAHO's mission statement emphasizes the organization's commitment to quality: "To continuously improve the safety and quality of care provided to the public through the provision of healthcare accreditation and related services that support performance improvement in healthcare organizations."

JCAHO evaluates and accredits nearly 17,000 healthcare entities, including:
  • Hospitals
  • Healthcare providers
  • Healthcare networks
  • Managed care plans, delivery networks, PPOs, HMOs, etc.
  • Home health service providers
  • Nursing homes, long-term care facilities, and assisted living facilities
  • Behavioral healthcare organizations
  • Hospice services
  • Ambulatory care facilities
  • Rehabilitation facilities
  • Laboratory facilities
  • Other healthcare organizations

To obtain JCAHO accreditation, organizations undergo an on-site survey that concentrates on key functional areas with a focus on safety and quality of care. JCAHO has identified applicable standards developed from consultation with industry experts, providers, and consumers for each institution type. These standards provide a baseline for evaluation.

In 1997, JCAHO launched the ORYX program to add substantive, quantitative measurements to its accreditation process, further reinforcing its value. The ORYX effort includes the collection of specific outcome or "core" performance measures identified by institution type. Inspectors then forward data via a compliant performance measurement system to JCAHO for evaluation and consultation during the on-site survey. The process will identify minimal standards, with a focus on process improvement.

JCAHO will stagger implementation of ORYX core measures across institution type. Beginning in July 2002, hospitals were required to begin collecting discharge information in four core areas: acute myocardial infarction, heart failure, community-acquired pneumonia, and pregnancy and related conditions.

Initial measures for other institution types are under consideration, and JCAHO will propose additional measures over time.

A compliant performance measurement system will be responsible for collection and submission of performance data. This automated system will generate internal comparisons over time and create external comparisons with other organizations' data for measurement indicators. The key attributes of this system include:
  • A set of processes or outcomes to be measured.
  • Support for the collection, analysis, and submission of measurement data.
  • An automated database to store and facilitate process improvement.

JCAHO has provided healthcare institutions with a list of compliant systems and attributes from which to choose.

JCAHO accreditation is a highly desired mark of an institution's quality for healthcare organizations. It may also have a direct effect on Medicare and Medicaid certification. The Centers for Medicare & Medicaid Services partially relies on accreditation organizations to judge compliance with federal standards.

For healthcare IT professionals, selection, implementation, and support of performance measurement systems will be a requirement. For more information on JCAHO and the ORYX initiative, check out JCAHO's Web site.

This article originally appeared in TechRepublic'sHealthcare IT TechMail.

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