The Joint Commission’s ORYX initiative integrates performance measurement data into the accreditation process.  ORYX measurement requirements support Joint Commission accredited organizations in their quality improvement efforts.

The Joint Commission is more than just an accrediting body. We are actively engaged in helping organizations improve their patient safety and quality of care. As it relates to Performance Improvement, these quality and safety efforts are demonstrated by documenting elements of patient encounters, e.g. How long did it take for a patient with stroke symptoms to receive a head scan? How long did it take for a patient to arrive in the ED and be treated before being discharged or admitted?

Hospital’s document all aspects of the care provided by collecting data from those encounters.

Here’s an example: Pat the Patient arrives in the Emergency Department. Staff document the amount of time (in minutes) it takes from the time the physician decides to admit Pat into the hospital from the Emergency Department, until Pat leaves the Emergency Department to go to the inpatient unit.

Staff document this information in the medical record for all encounters that fit that criteria.

In our example, the median time for this to occur for a sampling of Emergency Department patients like Pat is 225 minutes over the course of the first quarter of the year.

MEASURE EXAMPLE - ED-2: Admit Decision Time to ED Departure Time for Admitted Patients: Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care. Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment.

Performance Measurement data is submitted to The Joint Commission by all organizations with ORYX performance measurement requirements. The data is analyzed by statisticians at The Joint Commission and feedback is provided to facilities via Accelerate PI Dashboards. Measures which meet the Joint Commission accountability criteria are published on Quality Check® (see question 3.1 for more information on Quality Check)

For the hospital, this information shows trends in the care provided on measures over time, as well as how the organization is performing compared to others. By providing feedback, hospitals can identify opportunities to improve patient safety and quality of care.

For the Joint Commission, this information is used to generate national benchmarks and identify opportunities for improvement in clinical topic areas. In addition, this information is available to surveyors, so they may discuss Performance Improvement efforts your organization may enact as a result of seeing trends or spikes in patient quality of care and outcomes.

Organizations begin collecting ORYX Performance Measurement data the first calendar quarter following the receipt of their accreditation decision letter:

If the letter is received between 10/1 and 12/31, begin collecting 1Q data effective 1/1 patient discharges
If the letter is received between 1/1 and 3/31, begin collecting 2Q data effective 4/1 patient discharges
If the letter is received between 4/1 and 6/30, begin collecting 3Q data effective 7/1 patient discharges
If the letter is received between 7/1 and 9/30, begin collecting 4Q data effective 10/1 patient discharges

Note: Organizations are encouraged to keep up to date on any changes in the ORYX requirements by reviewing recent issues of The Joint Commission Perspectives^® or by going to the “Measurement” area on The Joint Commission website: http://www.jointcommission.org.

As a condition of participation (APR.04.01.01) organizations collect performance measures to meet specified ORYX measure reporting requirements for accreditation. The Joint Commission’s ORYX initiative integrates performance measurement data into the accreditation process. ORYX measurement requirements support Joint Commission-accredited organizations in their quality improvement efforts.

Elements of performance:

1. The organization collects measures relevant to their patient population to meet its current ORYX requirements.

2. The organization discusses with the surveyor how the data are used to identify, prioritize, and monitor performance improvement activities.

3. The organization uses each individual measure to identify patterns, trends, or variations for improvement opportunities.

4. Based on Joint Commission statistical analysis, the organization continues to use a measure in performance improvement activities and determines if the data suggest an unstable pattern of performance or otherwise identify an opportunity for improvement.

5. The organization resolves data quality issues for reported performance measures.
   For the most recent 12-month calendar reporting period, the organization achieves and sustains an acceptable level of performance, as defined by Joint Commission statistical analysis, for each measure before it discontinues its use in performance improvement activities.

6. The organization ensures that organization-specific data for its performance measures are submitted to The Joint Commission, in accordance with timelines established by The Joint Commission.

The Health Care Organization Identification number (HCO ID #) is not the same as CMS’ CCN. The HCO ID # is a unique number assigned by The Joint Commission. The Joint Commission’s HCO ID # can most easily be found when logged into your organization’s Joint Commission Connect Extranet site, shown in the upper right-hand corner, under the facility name and address.