Schyve, Paul

Loyola University Chicago, School of Law: LAW eCommons

Annals of Health Law
Volume 16
Issue 2 Summer 2007 Article 15
2007
Transcribed Speech of Dr. Paul Schyve
Paul Schyve
Joint Commission on Accreditation of Health Care Organizations
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Recommended Citation
Paul Schyve Transcribed Speech of Dr. Paul Schyve, 16 Annals Health L. 385 (2007).
Available at: http://lawecommons.luc.edu/annals/vol16/iss2/15
Transcribed Speech of Dr. Paul Schyve
DR. SCHYVE: I'm really very pleased to be here and would like to give
you a quick overview of how performance value is being used for some
other purposes, particularly the purposes of accreditation and self-
improvement within healthcare organizations. I believe you have a copy of
these slides in the folder.
As I was walking in, I was noticing the signs on the windows and there
were some clever sayings. One of which was something along the line of
we should rely on ethics rather than our palm pilots. So for once in my life,
I'm actually going to turn it off.
The Joint Commission is just a single factor [in] the healthcare industry.
We accredit eighty percent of the hospitals in the United States, which is
about ninety-six percent of the hospital beds. We also accredit long-term
care, home care, et cetera, but not at that level of penetration. [Thus], most
of what I'm talking about will be about how you relate performance value
specifically to hospitals. I will first talk about how we use [performance
value] to focus self-improvement within the organization and how we use it
to focus the on-site visits. The on-site visit is part of an external evaluation,
but obviously [it]'s what goes on within the organization that we're trying
to foster.
I will talk about three survey reports that we send to the hospital and to
the surveyor that are [used] during the surveying by the survey team. I'll
talk about public reporting of data, of what we put on the map. Finally, [I
will discuss] the strategic surveillance system, which is specifically
designed as helpful information for the organization to make improvements.
The accreditation for participation requirements includes the idea that
hospitals have to choose three of five currently available matrix sets. You
have myocardial infarction, heart failure, pneumonia prevention, and
pregnancy. [Hospitals] have to then take the whole set, whatever three
things they choose. So there could be [approximately] three to eight
measures within a set.
Secondly, they transmit that data monthly to a vendor, a performance
measurement system, which analyzes the data. [The vendor] provides
[hospitals] with some feedback and quarterly sends that data to the Joint
Commission. The data that we [receive] is de-identified, so we do not have
in that data individual information about individual patients. About 3,800
hospitals provided data in 2002, so it's a fairly large data mix.
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Schyve: Transcribed Speech of Dr. Paul Schyve
Published by LAW eCommons, 2007
Annals of Health Law
Now, the first way we use this system is something that we call a priority
focus process. We do this actually with the organization annually and I
hope [hospitals] would [set priorities] specifically before the survey, even
though [the survey is] in-house about every three years. This system is
based on an expert system and it uses extra survey data.
This is a picture of how the system works. On the left-hand column is
the kind of data that we get, which is not related to the survey process itself
except for the very first bullet-what we got from previous surveys in this
organization. The data comes from the Office of Quality Monitoring. [The
data includes] complaints about healthcare organizations, data from the
survey application, core measure data, and specific performance measures
(those three out of five sets that people are choosing). We also get the [per
bed] data. Mortality rates and length of stay [data] comes from the federal
government.
When we're doing this for nursing homes we use the nursing home
compare data, and for home health we use the home health compare data.
Also, for labs we use efficiency processing.
We go through a process, which is rule-driven. These rules have been
identified through literature review and expert advice. There're about 1,500
rules, if you see this over here to the left-hand column or you see this
combination of things in the left-hand column, those rules help us identify
what we've called in the right-hand column, Priority Focused Areas and
Clinical Service Groups.
The Clinical Service Groups are fairly obvious depending on what kind
of organization you are; if you're a hospital, it might be in cardiology.
Priority Focused Areas are those areas that, in fact, if you look at standards
for healthcare organizations, they fall into a number of groups and those are
the main groups that turn out to be issues for healthcare organizations.
Now, we also can calculate an overall cold score based on how the
organization has come out in those groups and see whether there was a
difference in score between different types of organizations. If you start at
the left [and move to] the right end, you'll see that, in fact, those
organizations that actually are entered in the preliminary accreditation or
additional accreditation had high scores, lots of points. If their organization
has the for-cause unannounced survey and we suddenly go in because of
something we received, their point score is 243. It's lower, but it's still
higher. All these differences provide us with different statistics.
A random control group of Joint Commission-accredited organizations
work [less efficiently] and we said to [this group], what kind of lists do you
sometimes look at to see where you think probably some of the best
performers are? And they say, well, there's the U.S. News list and there's a
solution and benchmark group, so we compare to those. And, again, that
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Transcribed Speech of Dr. Paul Schyve
makes sense to the fact [that] they had even lower scores. So this gives
some validity to the fact that what happens when you put through this set of
1,500 rules is, in fact, you end up with something that apparently [links] up
externally other kind of measures. This does mean something about the
organization and at least its overall performance. And where these priority-
focused areas do tend to be is the specific issue you should be looking at.
And now, we then take that information provided annually to the
organization, but we also provide it up front to the surveyor and it helps us
find where the survey group should be on the survey. In a pre-survey
report, we also looked specifically at that order and measured it. [O]n the
one hand, of course, we had years of data preceding any given survey. And
this is also available to the hospital through a secure connection, so it's not
singular to us. They have the same information to use for improvement
purposes. [We] have two basic things we're showing: control shutters
which [show] how reliable your process is, how stable your process is; and
[second], compares the charts that show your ultimate performance. [This
allows hospitals to ask] how does that compare to others?
So if you look at this, for example, this one would be for a particular
organization and it's got three core stats-heart failure, heart attack, and
pneumonia in the upper right table--and this tells something about where
they had problems and where they were doing particularly well. So for
example, the heart failure has the exclamation point, which means you may
have a problem here. You probably want to look at that. The other two
have pluses, which mean actually you're doing better than average on that
test. [T]he key is down at the bottom.
Then [hospitals] can break it down and not just look at heart failure, but
what the specific measures [are] for heart failure, for heart attack, and so on.
This table will show that. [T]he little squiggly thing is actually flow charts
that say this is one of the matters where there's a question about whether
you have a stable process or whether your results keep jumping up and
down. Again, the pluses and the exclamation point [are] the second thing
on there.
[Here], they actually show them in a flow chart. It's that upper left-hand
graph, which now shows what has been happening over time and how a
patient is in this variation. [A]lso, some places right in the middle of it right
at the bottom--the log in actually goes below that line that's across there.
[This] means, to me, that something happened at this time because it looks
strange.
[T]here's a number of rules that we apply that will say when you can
really pay attention to that flow chart, if you go outside of those lines.
Another thing, if you have eight points, for example, all on one side of the
average, but what's happening is, you've got eight points above the
2007]
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Schyve: Transcribed Speech of Dr. Paul Schyve
Published by LAW eCommons, 2007
Annals of Health Law
average. Something is changing or likely changing. On the right-hand side,
you'll see what we call the comparison chart, so the docket sets where the
organization's performance is and these bars--4he vertical bar between the
two edges is what you would expect statistically-are where you'd expect
this organization to be if it was like everybody else. So the first thing you
see [is] they are higher. You do the math. And the little numbers below it
are actually the literal numbers if you look at those numbers.
Now, that's what we use as part of the accreditation process; we're using
this performance data. The [data] help us focus the accreditation
process-what should the surveyor look at, what practice areas, and what
kind of things do you teach, and so on. Secondly, it helps the organization
understand where it should try to improve. And finally, third, it actually
gets the information out that can be provided with public reporting and we
put this on the web site, available for everybody. [W]hat it essentially does
is summarize.
[For example], this says heart attack, heart failure, and pneumonia. The
check mark means they're doing what would be average performance. On
the other hand, if they get one of these pluses, it means that it's above
average performance and a negative means that it's below average
performance. Obviously, sometimes there's so little data [that] we have to
say we can't do an evaluation for this organization.
So, if somebody wanted to tell you I'm particularly interested in heart
attack, like some of you might be, I would [ask about] some of the details
here, not just raw [data]. So now you're actually looking for specific
measures and how we get those specific measures. [T]hose percentages tell
where those [specific numbers] appear and [where] others will be across the
United States and across the state.
[F]inally, let me turn to [something] we're now developing that will
become available in 2007, called Strategic Surveillances. It's how do
[hospitals] make use of what they already have? So we've got all this data
that includes these performance figures. Is there more that we can do with
that than what I showed you [in order] to help organizations improve? And
so this doesn't require organizations to spend any [more on] additional data
than what is already available to them.
It's one price [for the suite], and there's really two that we're starting
with. One is the performance risk assessment and the second one is the
performance measure compared. The performance with risk assessment
comes from the priority focus process of which measures will be tied. And
the second one, performance measure compared, is based just on the risk.
So the performance risk assessment will be used in your organization and
will give you the following priority report.
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Annals of Health Law, Vol. 16 [2007], Iss. 2, Art. 15
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Transcribed Speech of Dr. Paul Schyve
Here's a report that tells them how they're doing in each of those
performance areas: assessment, communication, gradual accreditation,
equipment usage, and how they're comparing to others (in this case the
national comparison group). Numbers are reversed from what we saw
before, because here the higher the number means you [have] more points
to span against the little dot. [S]o, the hand means you have to pay
attention to this [number]; it is a "stop sign," [because] the first [measure] is
twenty-six, whereas the national average was eighteen.
Now, suppose the hospital system has multiple hospitals and they can
actually see across hospitals how this, in fact, plays out. They can connect
and get this kind of report, which will tell them a couple things. One is,
suppose they had a series of things, "stop sign" hands, red ones all [the
way] down for almost every hospital under one of the topics-say infection
control. Now you know our system had better pay more attention to
infection control or they may see a row in which there's more of these [red
"stop sign"] hands. [Of] which the [hospital] says, "How do we compare
with that particular hospital?" [O]r you may see a row where it's all pluses.
Now the question is, can we learn from that hospital's best practices, which
we can spread to others within the system?
[F]inally, the performance measurement compared is now based just on
the performance with four measures. So you've chosen heart attack,
pneumonia, and congestive heart failure, but you'd like to know how you're
doing compared to not just the national average, but compared to other
hospitals--either the same type as you or another type. So now you get to
choose. You can see types of owners-government, but not federal. We
see non-governmental for-profit and non-governmental not-for-profit. You
can choose a bed [capacity]. You can do any one of these or you can do
combinations. You can choose a particular state. What you get is a kind of
report, which essentially tells you [how you] compared to the national
average, and also how you are doing compared to any particular comparison
group that you've chosen.
If you want more information about heart failure specifically, not just
how you did overall in heart failure, but how you did on each of those
individual measures, you can get the same type of information now for the
specific measures that are being used for heart failure or discharge
instructions. Was there an evaluation of function, was an Ace-Inhibiter or
ARB medication given upon discharge? That's what we're trying to do
with the data.
So this is, I think, another use of the data as part of a more integrated
valuation system, number one; and number two, as part of a process. Both
in integration, as well as with all the risk measures, [these measures] can
help organizations get more data to improve. Thank you.
2007]
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Published by LAW eCommons, 2007


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Transcribed Speech of Dr. Paul Schyve

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