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What’s in this section:
General Information about Perinatal Care Attestation
Examples
How to Attest
1. General Information
Hospitals can attest to submitting four quarters of ePC measures (eCQMs) instead of four quarters of chart-abstracted PC measures for their Perinatal Care measures via the Chart-Abstracted Submission menu.
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NOTE:One for one replacement: Correct: submit ePC-01 instead of PC-01 Not Correct: submit ePC-02 instead of PC-01 |
May replace none, some, or all required PC measures with ePC measures.
4 quarters of PC eCQM data = 4 quarters of the associated chart-abstracted PC measure data
If an organization is uncertain the eCQM data can be submitted (e.g., ePC-06), we strongly suggest the chart-abstracted data is entered until it is certain the eCQM data can be successfully submitted.
A PC measure submitted as a chart-abstracted measure for all 4 quarters, may also be submitted as an eCQM.
If applicable, every ePC eCQM submitted for 4 quarters counts towards both an organization's PC requirement and eCQM requirement.
2. Examples:
CY2023: 4 quarters of eCQM data = 4 quarters of chart-abstracted measure data
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CY2023 Example (eCQMs = 4 quarters of data)
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Example 1
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1Q
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2Q
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3Q
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4Q
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Comments
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Chart-abstracted
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Y
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Y
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Y
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Y
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HCO submits all 4 quarters of only chart-abstracted measures; no ePC eCQM data are used to meet the Perinatal Care Requirment. HCO is required to submit 4 other (non-ePC) eCQMs.
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eCQM
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N
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N
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N
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N
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Example 2
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1Q
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2Q
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3Q
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4Q
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Comments
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Chart-abstracted
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Y
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N
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N
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N
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HCO submits first quarter of chart-abstracted PC measures and 4 quarters of ePC eCQM data; receives feedback on all data submitted. ePC eCQMs are counted towards the hospitals perinatal AND eCQM requirement.
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eCQM
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Y
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Y
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Y
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Y
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Example 3
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1Q
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2Q
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3Q
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4Q
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Comments
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Chart-abstracted
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N
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N
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N
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N
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HCO does not submit 1Q chart-abstracted PC measures and is required to submit 4 quarters of ePC eCQM data. ePC eCQMs are counted towards the hospitals perinatal AND eCQM requirement.
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eCQM
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Y
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Y
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Y
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Y
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Example 4
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1Q
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2Q
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3Q
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4Q
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Comments
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Chart-abstracted: PC-06
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Y
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Y
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Y
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Y
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HCO submits 1 chart-abstracted measure (e.g. PC-06) for all 4 quarters.
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eCQM:
ePC-01, ePC-02, ePC-05
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Y
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Y
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Y
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Y
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HCO submits 4 ePC eCQMs (e.g. ePC-01, ePC-02, ePC-05) for 4 quarters. ePC eCQMs are counted towards the hospitals perinatal AND eCQM requirement. Hospital must submit one additional eCQM.
3. How To Attest:
Click on the open button for the Perinatal Care measure for which you wish to attest to submit via eCQM.
Select the toggle on the right-hand side, “Attest to submit via eCQM”. By clicking on that toggle, you are attesting that you will be submitting this measure as eCQM data instead of aggregate chart-abstracted data.
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This attestation begins with the currently open quarters for which aggregate data has not already been submitted, as well as applying to future quarters of the specified measure.
Aggregate data which has already been submitted, including the open quarters, will continue to be used by The Joint Commission.
If aggregate data has been entered into open quarters, you may delete it prior to attesting to submitting eCQM data. However, if data was entered for closed quarters, that data may not be deleted because it was already used in Joint Commission analysis.
3. After clicking the attest toggle, you will see the following message under the quarter tabs: “Attest to submit via eCQM has been selected and as a result this data may no longer be changed”.
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4. If you return to the Measure List page, this chart-abstracted measure will now be shown as complete for all open quarters.
5. Note that while “Attest to submit via eCQM” is selected, you cannot change or remove already entered Chart-Abstracted data for that measure.
6. If you previously selected “Attest to submit via eCQM” but now wish to enter chart-abstracted data instead for an open quarter, simply click on the toggle to turn the attestation selection off. This will allow you to enter chart-abstracted data for each open quarter.
7. When “Attest to Submit via eCQM” is selected, the chart-abstracted data may no longer be changed. The data are visible within the Chart-Abstracted module as a reference for what was or will be submitted. This action applies to all open and future quarters."Refer to this topic under, “General: Perinatal Care Attestation on the DDSP”: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/25231379