April 1997

JCAHO Tries Again

J. Duncan Moore, Jr

.Modern Healthcare 1997; 27:2-3.

[ Link to the Modern Healthcare website ]

Following almost 11 years of confusion, the Joint Commission on Accreditation of Health Care Organization (JCAHO) just unveiled its latest plan to base accreditation, in part, on provider performance. Since its inception in 1951, the JCAHO used capacity for provision of high quality care as the basis for judging hospitals and other health care providers.

The capability of providing quality health care has been measured by adherence to quality assurance standards determined from provider-generated reports and JCAHO on-site surveys. The implication from this process was that accreditation equates in some manner to high quality performance. The next evolutionary step in JCAHO accreditation, termed "ORYX", will require heath care organizations to gather and submit data about the results of their care. As a matter of interest, the term "ORYX" is apparently not an acronym, but simply a term chosen to emphasize an accreditation process significantly different from anything that JCAHO has done before. It has been noted, sometimes humorously, that an ORYX is also a deer-like animal which is occasionally seen in zoos.

As currently envisioned, the ORYX process will apply initially to hospitals and nursing homes, who must choose a performance measurement system from a list of 60 approved vendors of information systems by the end of this year. Following that, they must submit data on two clinical indicators which apply to at least 20 percent of the patient population by the first quarter of 1999. Over a several-year period, the number of indicators and percentage of patients covered in the program will increase.

Beyond hospitals and nursing homes, health plans, integrated delivery networks and provider-sponsored organizations will participate in a modified program, while ambulatory care, behavioral health, laboratory and home care organizations will be entered into the ORYX process about a year later. This program will be explained in a manual distributed to providers next month. Hospitals will pay $10 per indicator per quarter to the JCAHO (minimum $80/year). Start-up costs are expected to be around $10,000 with maintenance costs about $11,000 per year.

It has been observed that a number of possible components are conspicuously absent from the ORYX accreditation process. First, there is no requirement to make the performance data public. Second, institutions will be required to submit only two clinical indicators or their choice. Thirdly, the JCAHO has not expressed an intention to compile all the submissions into a data base that it would control.

Fourth, the basic ORYX process will not be able to compare the outcomes among various hospitals, but rather foster competition within each hospital itself. Finally, it appears that accreditation will at least not be initially revoked on the basis of single unsatisfactory outcomes.

Using this more data-driven process, spokesmen for the JCAHO suggests that ORYX will provide a means of assessing performance improvement. Accreditation will continue to be based on standards, however, not solely performance. Because no single measurement can be indicative of improvement, it is argued that no institution would lose accreditation on this basis alone.

When questioned about why it has taken over a decade to finally get to this point of objectivity in assessment of quality, Dr. Dennis O'Leary, President of the JCAHO, stated "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've reached today. I don't feel bad about it. I feel pretty good we got to this point in ten years."

It will be interesting to see if our culture and the instruments evolving to describe our health care process have progressed sufficiently to make the move toward accreditation based on outcomes.