Clarification of TJC S3 Scoring

Have you noticed your TJC S3 score rising? Has it risen markedly over the last two quarters? If so, you may have some questions that you’ve had trouble answering. Hopefully, we can provide some insight that will prove helpful. In discussions with the folks back in Chicago overseeing  S3 scoring (who have been most helpful), there was a bump in Quarter 2 ‘08 reported data that most hospitals felt, which was due to data from SCIP measures. TJC had neglected to factor in the SCIP ORYX (core measure) outcomes into the scoring system as they have with all other ORYX measures. So, suddenly, quarter 2 ‘08 reflected this data and caused a sudden (and in many cases, distinct) rise in S3 total. Another issue with rising  S3 scores is the fact that only the negative outliersfrom all ORYX measures are counted in the S3 scoring. Core measure outcomes are counted in the S3 scores for a total of eight rolling quarters, with the first quarter falling off as the ninth quarter becomes the eighth quarter. Currently there are only 7 quarters available for data capture. So what happens is this; if your hospital has 3 quarters in the 7 quarter period that were outliers, and these outlier quarters started with the first outlier appearing in the 2nd quarter, that first outlier isn’t going to roll off for two quarters. What we are hearing is that hosptials are confused because they have 2 to 3 quarters of complete compliance (no outliers) with their core measure data showing significant improvements, and they expect their S3 score to reflect this improvement. However, because TJC only counts the outliers in the S3 scoring (to reiterate, they do NOT count the compliant quarters) those “negative” quarters will stay with the hosptial until the specific outlier quarter rolls off. That means the hospital with the first outlier in the 2nd quarter, won’t start showing a lower S3 score for six months, because two quarters have to roll by unitl the 2nd quarter rolls off. Confusing? You betcha. Does it seem fair? Not really. However, this is the current scoring system. And remember, the S3 score takes into account Med Par data, prior survey findings and any complaints or Sentinel Events your hospital may have on file with TJC, so core measure data isn’t the only factor in the S3 scoring. However, if you look at how your data maps to your score, core measure outcomes do drive the lion’s share of the calculation. Because the people overseeing the S3 scoring appear to be trying diligently to help hospitals understand the scoring system, we encourage you to call TJC with any questions concerning your score, we have found the folks at Oakbrook Terrace to be very helpful.