The joint commission established an initiative known as oryx. what was its’ purpose?

Fig. 32.1

Foundations of evidence based medicine (EBM) [2]

EBM is the practice of using data from studies comparing the efficacy of multiple interventions or treatments to guide clinical practice. Quality metrics have their origin in EBM which in turn developed out of application of findings of clinical epidemiology. Parallel to developments in research techniques were social factors that combined to lead to the development of quality measures and the current health care landscape.

The quality measurement and improvement initiative began in the late 1990s with the development of a consensus recognition amongst healthcare providers and industry leaders that a disconnect existed between the care that should be delivered and that which was actually delivered.

The Institute of Medicine established six aims of improvement to address areas where the health care system underperforms. They postulate that healthcare should be: safe, effective, patient centered, timely, efficient and equitable [4]. National efforts to describe where and to what extent the health care system underperforms led to the passage of the title IX of the Public Health Service Act (42 U.S.C. 299 et seq.). Section 913 (a)(2) of the title outlines the creation of the Agency for Healthcare Research Quality (AHRQ) and charges the agency with generating “an annual report on national trends in the quality of healthcare provided to the American people.” This annual report, known as the National Healthcare Quality Report (NHQR) or Quality Report for short, was first published in 2003 and outlined five key findings:

1.

High quality health care is not yet a universal reality
2.

Opportunities for preventative care are frequently missed
3.

Management of chronic diseases presents unique quality challenges
4.
5.

Greater improvement is possible

The first national program for the measurement and reporting of hospital quality was started by the Joint Commission in 1998 with its ORYX initiative [5] The Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations- JCAHO) is an independent not for profit organization that accredits and certifies more than 19,000 health care organizations and programs in the United States. In 2002, hospitals accredited by the Joint Commission were required to collect and report non-standardized data for two four core health measures (heart failure, acute myocardial infarction, pregnancy and pneumonia). These data were first made available to the public in 2004 [6].

Any attempt to improve a process first begins with a definition of what the goal of improvement is. In the realm of health care delivery and patient care, this necessitates the definition of quality health care. The most concise definition comes from the National Committee for Quality Assurance (NCQA), a private not-for-profit organization founded in 1990 that collects annual data from providers and health plans and compares the results against developed standards in order to effect change. The NCQA defines quality health care as the “extent to which patients get the care they need in a manner that most effectively protects or restores their health” [7]. According to the NCQA this includes receiving preventative care as well as timely access to effective, evidence based medical treatments. The ultimate goal of these interventions as outlined in their vision and mission statements is to improve/transform health care quality through measurement, transparency and accountability.

The NCQA uses a continuous three stage cycle of measurement, analysis and improvement to drive change. Self-reported data in more than 40 areas are obtained from health plans and providers on an annual basis. The NCQA has developed standards in conjunction with health plans, large employers, patients, doctors and policy makers so that consensus could be reached on which outcomes are important to measure and how to measure them. The comparison of self-reported data on an annual basis with standards established by the NCQA becomes the substrate organizations used to develop focused health care quality improvement initiatives and to create agendas within an organization for subsequent years.

As outlined by the Institute of Medicine (IOM), quality improvement initiatives should aim to develop systems that are safe and designed to avoid injury as well as provide services that are effective, patient centered, delivered efficiently and in an equitable manner. To achieve these aims, quality metrics should have “scientific validity, specification of numerators and denominators, and certainty that a potential measure is interpretable, applicable, and feasible” [4].

Often confused with guideline recommendations, performance measurements are used to construct a framework for the boundaries of care. As outlined by the American College of Cardiology Foundation and the American Heart Association (ACCF/AHA) task force on performance measures, “performance measures identify aspects of care for which the failure to provide a particular process of care is judged as poor clinical performance” whereas practice guidelines delineate “processes of care that should that should generally be used in patients with a given condition” [8]. As highlighted by the writing committee to develop heart failure clinical performance measures in 2005, development of quality metrics aims to capture implementation of those processes or structural aspects of care whose supporting evidence “is so strong that failure to perform such actions reduces the likelihood that optimal patient outcomes will occur” [9].

Once the goal of a quality improvement initiative has been identified, the individual(s) or group undertaking the initiative need tools to study existing processes and the outcomes they result in. Outcome measures quantify high level safety, patient care and financial endpoints that indicate how well an organization is meeting its goals. Ideally, outcome measures specify a population to study and a specific timeline over which the measure would be applied.

Process measures assess the specific steps or tasks in a pathway that lead to a specific outcome metric. Several process measures can be studied sequentially to codify the steps that lead to the outcome measure of interest (Fig. 32.2). While outcome measures can be used to measure the overarching goals and directions for a healthcare organization, process measures are used to steer granular interventions towards these goals.

Fig. 32.2

Relationship of process measures to outcome measures

Health care quality metrics are developed for a wide array of audiences and reasons. Patients and purchasers may use them when deciding on providers and plans, institutions and individual providers may use them as tools to drive performance improvement initiatives, assess resource utilization or compare themselves with competitors. Donabedian proposed in 1991 that the quality of healthcare could be assessed by assessing its structure, process and outcomes [10]. In the United States, the IOM defines healthcare quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” [11].

Process measures provide information about health care delivery that can be used to affect change within a system. Process measures carry the additional benefit of requiring littleDOUBLEHYPHENif any, risk adjustment for patient illness. The development of a process measure requires identification of an eligible population to which the measure is then applied [12]. An example would be to measure the percentage of all patients with left ventricular systolic dysfunction (eligible population) that have been prescribed and angiotensin converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB).

Chassin and colleagues proposed that process measures be judged against 4 criteria in order to maximize their relevance to clinical outcomes [5]. Measures should: be grounded in strong evidence linking the process of care to improved outcomes
accurately capture whether or not the process of care being measured was performed
address processes that have few intervening processes of care between the one being measured and the outcome that is targeted
have small to no chance of inducing adverse events

In Crossing the Quality Chasm, the IOM makes the case that focusing on specific conditions provides added meaning to patients as well as those involved in the utilization, delivery, strategic implementation or purchasing of health care [4]. In addition to aligning the multiple stakeholders involved in healthcare delivery and utilization, prioritizing disease conditions can help combat forces that fragment and misalign the health care system and stifle systematic quality improvement efforts.

Heart Failure is an important national public health issue with widespread prevalence, significant morbidity, mortality, and cost implications for patients, providers and payors (both public and private). Of all diagnoses, more Medicare dollars are spent on congestive heart failure diagnosis and treatment than any other in the United States. An estimated five million Americans live with the diagnosis and an additional 550,000 diagnoses are made each year [13]. Understanding of the pathophysiology of the disease has led to the development of non-invasive, pharmacologic and biomechanical tools to diagnose and treat heart failure. Despite these significant advances, evidence indicates that the implementation and use of these new tools falls below that which might be expected.

The NCQA describes the fragmentation of the United States health care system as one in which “episodic care is delivered by a range of providers who are not as well-connected to one another as they should be” [14]. Furthermore, “poorly coordinated care is frequently lower quality, more expensive and can result in poor health outcomes.”

In February 2000 the AHA/ACCF Task Force on Performance Measures was created to develop guidelines across the scope of cardiovascular disease care. In 2003 the ACC, AHA and Physician Consortium for Performance Improvement (PCPI) developed measures for heart failure patients that received care in the outpatient setting. The ACCF and AHA first developed inpatient clinical performance measures for adults with chronic heart failure in 2005 [9] Five inpatient measures and 11 outpatient measures were proposed based on 2005 ACCF/AHA class I and class III guideline recommendations for the diagnosis and management of heart failure as well as the Team Management of Patients with Heart Failure: A statement for Healthcare Professionals From the Cardiovascular Nursing Council of the American Heart Association. These measures were most recently updated in May 2012 by the Heart Failure workgroup and published in conjunction with the PCPI. This updated measure set expanded its scope to include guidelines from the European Society of Cardiology and the Heart Failure Society of America (HFSA) [15].

Measures put forth by the (ACCF/AHA/PCPI) in the 2012 update have been streamlined to include both the ambulatory and hospital care settings with the aim of quantifying processes (process measures) in patients with heart failure meant to favorably influence morbidity and mortality (outcome measures). Five outpatient measures and three inpatient measures from the 2005 version of the guidelines were retired with this update. Currently, nine measures exist divided into three groups- outcome measures, process measures and paired/bundled measures (Tables 32.1 and 32.2) [15].

Table 32.1

ACC/AHA attributes for satisfactory performance measures [15]