ORYX Initiative by krx12803


									Stony Brook University Hospital                                  2008-2009 Quality Management Annual Report

ORYX Initiative                                           The following ORYX core measure sets/indicators are
ORYX is the name of the Joint Commission’s initiative     reported and analyzed by leadership groups and other
to integrate performance measures into the                fora to address opportunities for improvement:
accreditation process. It is a term different from any
other currently used in healthcare, reflecting the        Pregnancy and Related Conditions
magnitude of changes in the Joint Commission’s               • Vaginal birth after caesarean section
accreditation process.                                       • Inpatient neonatal mortality
                                                             • Third or fourth degree vaginal laceration
The Joint Commission’s accreditation process has
become data-driven. The use of outcomes-related           Acute Myocardial Infarction
data in accreditation activities serves as a greater         • Aspirin at arrival
stimulus for healthcare organizations to examine their       • Beta blocker at arrival
processes of care and take action to improve the             • Aspirin prescribed at discharge
results of care. The long-range goal of the ORYX             • Beta blocker prescribed at discharge (retired
initiative is to establish a data-driven, continuous             after Q1 2009)
survey and accreditation process to complement the           • ACE Inhibitors or angiotensin receptor blockers
standards-based assessment.                                      (ARB) for left ventricular systolic dysfunction
                                                             • Adult smoking cessation advice/counseling
Previously, health care organizations were required to       • Time to thrombolysis
collect data on non-standardized measures to evaluate        • Time to PTCA
processes and develop opportunities for improvement.         • Inpatient mortality
ORYX now utilizes standardized performance
measures, called core measure sets, to support            Community Acquired Pneumonia
comparison across health care organizations. Each            • Oxygenation assessment (retired after Q4
core measure set has individual measures to evaluate           2008)
specific areas in each category. The core measure            • Pneumococcal screening and/or vaccination
sets will allow for standardized data collection,            • Blood culture performed within 24 hours
established evaluation criteria, comparisons of              • Blood culture performed before first antibiotic
performance over time, and the use of benchmarking             received
studies.                                                     • Adult smoking cessation advice/counseling
                                                             • Antibiotic timing
Stony Brook University Medical Center utilizes the           • Antibiotic selection
United HealthSystem Consortium (UHC) database to             • Influenza vaccination status
report indicator data to the Joint Commission.
Quarterly reports benchmark the organization against      Surgical Quality Improvement Project
others using the UHC system for the indicators               • Prophylactic antibiotic received within one hour
selected. Decisions to select specific ORYX indicators           prior to surgical incision
were accomplished under the direction of quality             • Prophylactic antibiotic selection for surgical
management and in conjunction with the Medical                   patients
Executive Committee and, more recently, the Quality          • Prophylactic antibiotics discontinued within 24
Committee of the Governing Body.                                 hours after surgery end-time (48 hours for
                                                                 cardiac surgery)
The Quarterly reports are provided to the Chief Quality      • Cardiac surgery patients with controlled 6 AM
Officer and the leaders associated with particular               post-operative serum glucose
ORYX indicators (e.g., Heart, Perinatal and Medicine         • Surgery patients with appropriate hair removal
Clinical Service Group members) by the Quality               • Colorectal Surgery Patients with Immediate
Management liaisons to the Clinical Service Groups.              Post-operative Normothermia
These reports are shared among the appropriate               • Surgery Patients with Recommended Venous
various fora for discussion and potential action. If             Thromboembolism Prophylaxis Ordered
necessary, performance improvement teams may be              • Surgery Patients Who Received Appropriate
formed or clinical guidelines may be designed to                 Venous Thromboembolism Prophylaxis Within
address opportunities for improvement. Based upon                24 Hours Prior to Surgery to 24 Hours After
the ORYX report, decisions are made as to the                    Surgery
direction that should be taken by the organization to        • Surgery patients on Beta Blocker Therapy prior
improve performance.                                             to admission who received a Beta Blocker
                                                                 during the peri-operative period (effective Q1

ORYX Initiative

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