Strategic Surveillance System (S3): Dispelling the Myths
Organizations not affiliated with The Joint Commission produce products and sponsor education programs related to Joint Commission accreditation. At times, the information provided in these products and programs is confusing, misleading, or inaccurate. The Fact on Fiction column identifies this misinformation with the intent of preventing confusion and correcting misperceptions in the field. This column is included in The Joint Commission Perspectives® on an “as needed” basis, whenever misleading or inaccurate information on Joint Commission initiatives is published. Questions about Joint Commission initiatives can be directed to perspectives@jcrinc.com.
About the Strategic Surveillance System
The Joint Commission officially launched the Performance Risk Assessment (PRA) tool of the Strategic Surveillance System (S3™) for the hospital program in July 2007 with the redesign of The Joint Commission Connect™ extranet site. S3-PRA is a management tool that hospitals can use to achieve maximum systems improvement by focusing energies and resources on strategic objectives. The tool provides a series of risk assessment and comparative-measures reports to help organizations improve their care processes and prioritize the actions to take for improvement. S3 is an added value to Joint Commission accreditation and use of the tool is voluntary. See the September 2006, March 2007, May 2007, June 2007, and September 2007 issues of Perspectives for additional background and information on S3.
Since the July 2007 launch of the Joint Commission’s Strategic Surveillance System (S3), 3,250 hospitals have accessed the tool with a weekly average of approximately 500 users [user data as of February 11, 2008]. Feedback from users has been positive, says Carrie Mayer, associate director, accreditation systems integration, Accreditation and Certification Operations, The Joint Commission. However, Mayer adds, even with positive feedback, there are always some misconceptions or myths. The following article addresses the misconceptions currently associated with S3.
Addressing the Myths
Myth: The Joint Commission uses our data
against us.
Mayer says some hospitals are worried about how the Joint Commission will use S3 data. “The Joint Commission is not using S3 data in the accreditation or survey process, nor do surveyors have access to any hospital’s S3,” says Mayer. Further, Mayer says that the Joint Commission will not make the S3 data publicly available. “This is simply a tool for the hospital,” Mayer says.
Myth: Smaller and specialty hospitals won’t find S3 valuable.
Mayer says that S3 is indeed useful for smaller and specialty hospitals. S3 can offer unique analyses and portrayals of data for these types of hospitals. To increase the usefulness of S3 for specialty hospitals, Mayer says that by mid-2008, the Joint Commission will implement additional comparison groups in S3, such as psychiatric hospitals, oncology hospitals, physical rehabilitation hospitals, pediatric hospitals, long term acute care hospitals, and teaching hospitals. The S3 tool will constantly evolve to meet the growing needs of the organizations using it.
Myth: S3 data are too old to be useful.
“We want to make this tool as useful as possible and will continue to enhance and reshape it as we receive feedback from users,” says Mayer. One aspect for which the Joint Commission has received criticism is in the use of MedPAR data. However, as Mayer points out, MedPAR data are widely used in research and analyses of performance, and she assures the health care field that the Joint Commission uses the most current publicly available data.
Myth: S3 can help us predict when we will be
surveyed.
Mayer addresses another common misconception—that S3 is a predictor of an upcoming on-site survey, which the Joint Commission has been conducting on an unannounced basis since 2006. “There is a myth out there that S3 can help users predict when, within the 18–39 month window, they will be surveyed,” Mayer says. “This is not true.” Mayer says that while this is a common misconception, she can understand the confusion. S3 does use Priority Focus Process data, and although the 18–39 month model will also use these data, additional statistical analysis and modeling not present or available in S3 are used to determine an organization’s survey date.
Future Plans for S3
The Joint Commission plans to continually expand and improve S3 data. Plans currently in development include the following:
- Quarterly data updates
- More comparison groups
- Better print options
- Useful trending views and reports
- Additional data sources, such as new ORYX® Core Measures, CMS 30-day mortality data, and CMS Hospital Consumer Assessment of Healthcare Providers and Systems data
- Expanding S3 to other accreditation programs, such as the home care (home health services only) and long term care programs
For more information about S3, visit the Joint Commission’s S3 Web page at http://www.jointcommission.org/AccreditationPrograms/Hospitals/S3/faqs_s3.htm.
Organizations are reminded and encouraged to refer to The Joint Commission Perspectives®, the official newsletter of the Joint Commission, and the Joint Commission Web site (http://www.jointcommission.org) for the most accurate, up-to-date information on Joint Commission policies, procedures, standards, and initiatives.