Page Comparison

• Source Viewer:This sdtc:dischargeDispositionCode SHOULD contain exactly [1..1] @code (TJC-0046)

  • Section / Element: Discharge Disposition Code 

  • The Discharge Disposition Code should only occur once.

• Source Viewer: This sdtc:dischargeDispositionCode SHOULD contain exactly [1..1] @codeSystem(TJC-0047)

  • Section / Element: Discharge Disposition CodeSystem

  • The CodeSystem should only occur once.

• Source Viewer:Event End date is before the Event Start Date. (TJC-100023)

  • Section / Element: High@value

  • All Event End Dates (@high) used by the eCQMs must be before the associated Event Start Date (@low).

  • Apply offset before validation.

• Source Viewer: Event End date is before the Event Start Date. (TJC-100024)

  • Section / Element: High@value

  • All Event End Dates (@high) not used by the eCQMs should be before the associated Event Start Date (@low).

  • Apply offset before validation.

• Source Viewer: There exists an inpatient encounter with discharge datetime outside of the reporting quarter defined in the Reporting Parameter of the QRDA document. (TJC-100036)

  • Section / Element: Encounter ID

  • At least one of the inpatient encounter's discharges datetime is outside of the reporting quarter.

• Source Viewer:There exists inconsistent encounter id, code/codeSystem, effectiveTime or principal diagnosis code in the Inpatient Encounter template for the same episode. (TJC-100025)

  • Section / Element: Encounter ID

  • When two or more inpatient encounters exist, they are processed as the same encounter if there:

    • admit and discharge dates are the same or

    • encounter IDs and extension are the same

  • If the same inpatient encounters are reported, only the valueset may be different. Everything else should be the same. This edit is triggered if any of the below conditions exist:

    • admit or discharge date is different

    • encounter ID or extension is different

    • encounter code/codeSystem is different

• Source Viewer:Two instances of inpatient encounter template are exactly the same. The last instance in the QRDA file will be used for measure evaluation. Remove duplicate encounter template/s to avoid unexpected outcome. (TJC-100026)

• Section / Element: Encounter ID

  • Admit and discharge dates, encounter code and encounter ID (root and extension) are the same among duplicates.

• Source Viewer: The CCN does not match with the CCN associated to the current HCO. (TJC-100032)

  • Section / Element: CCN

  • CMS' CCN in the QRDA I document does not match with the CMS CCN associated to the hospital for which the data was Uploaded.

  • The Joint Commission does not provide a 'bulk' upload function which allows QRDA I documents from multiple hospitals to be submitted within one zip file.  Instead, a zip file must be created and uploaded for each organization (based upon their CCN). 

    • Users with access to multiple hospitals may use the ‘Multi-HCO Batch Upload’ function to upload multiple zip files from one page.

    • If you need access to multiple hospitals, please contact the individual(s) for each hospital that have the "Invite & Manage User" functionality as The Joint Commission staff cannot on-board staff to a hospital's Workspace.

  • The Joint Commission processes all data submitted to the DDS Platform based upon the hospital's CMS CCN, not the hospital's Joint Commission HCO ID. The Platform crosswalks the CCN back to the HCO ID for data storage and analysis purposes.

    • You can determine the CCN which The Joint Commission has linked to your HCO ID by going into HCO Characteristics (available from the main menu).  If the CCN is incorrect, please complete the Support Ticket to inform us what the correct CCN should be and we will investigate.

Note: We have not built the functionality to receive a file containing solely our HCO ID due to our desire to reduce hospital costs and other burden.  By receiving the file using CMS' CCN, it allows hospitals to submit the same QRDA I document that they submit to CMS to The Joint Commission.

The CCN on file within the DDS Platform has been taken from your organization’s accreditation application - so it is possible it also needs to be updated there as well.

The 'Invalid DateTime’ error is associated to two Source Viewer messages:

• Source Viewer: Invalid DateTime has been provided. (TJC-100008)

  • Section / Element: DateTime

  • The Joint Commission validates all the date/time fields (e.g., effectiveTime, Time, and birthTime) that may be used in measure evaluation have a valid format. Valid Date/Time Format:  YYYYMMDDHHMMSSxUUUU  where

    • YYYY - year - range 1900 to 9999

    • MM - month - range 01 to 12

    • DD - day - range 01 to 31 (note: true to month and leap years)

    • HH - hour - range 0 to 23

    • MM - minutes - range 0-59

    • SS - seconds - range 0-59 x - plus or minus sign

    • UUUU - UTC time shift -1300 thru+1400

• Source Viewer: Invalid DateTime has been provided. (TJC-100012)

  • Section / Element: DateTime

  • The Joint Commission validates all the date/time fields that may NOT be used in measure evaluation.

  • Dates are evaluated for:

    • One or more part of dateTime field is not in the YYYYMMDDHHMMSSxUUUU format

    • Year must be in the range of 1900 to 9999

    • Month cannot be 00 or greater than 12

    • Day cannot be 00 and cannot be greater than 31

    • Day cannot exceed limit for month (Leap year calculation is validated)

  • Time formats in effectiveTime, time or birthTime elements (XML tags) are evaluated for:

    • One or more part of the Time field is not in one of these formats: HH, HHMM, HHMMSS, HHMMxUUUU, or HHMMSSxUUUU

    • HH may be between 00-23

    • MM may be between 00-59

    • SS may be between 00-59

    • xUUUU represents the UTC time shift and may be between -1300 thru +1400

    • x - plus or minus sign for the UTC time shift

    • UUUU - UTC time shift

Note:  We have determined that some vendors are defaulting values into date/time fields instead of submitting a ‘null’ value or Nullflavor when something did not occur.  Please refer to the Nullflavor discussion within CMS' Implementation Guide for QRDA I documents for an understanding of how missing or null datetimes should be submitted.

Two examples which trigger this rejection:

<effectiveTime xsi:type= "IVL_TS" >
<low value= "00010101000000" />  → the start date/time is defaulted as "00010101000000-0000"
</effectiveTime>

<effectiveTime xsi:type= "IVL_TS" >
<low value= "00" />   → the start time is defaulted as "00"
<high nullFlavor= "NI" />
</effectiveTime>

• Source Viewer: Invalid Patient ID has been provided. (TJC-100029)

  • Section / Element: Invalid Patient ID has been provided. (TJC-100029)

  • The Patient ID cannot be greater than 100 characters OR there are invalid characters.

  • Please contact your IT staff or EHR vendor if assistance is needed to correct this error.

Invalid QRDA I Documents typically cannot be displayed within the Source Viewer and it may appear as a preprocess validation error on the Data Accuracy bar chart.

There are two primary reasons for why the ‘Invalid QRDA XML file’ error is generated:

• Section / Element: XML File format issue

  • File does not confirm to being a valid HL7 QRDA I XML file.  Please review the file that you submitted using tools available within your organization or supplied by your vendor.

  • Please contact your IT staff or vendor that supplied the software being used to generate the QRDA I documents to correct this error.

• Section / Element: Patient ID

  • Only English alphabet characters, numeric characters, and the following special characters are allowed in the Patient ID:
     ~  !  @  #  $  %  ^  *  (  )  _  +  {  }  |  :  ?  `  -  =  [  ]  \  ;  ‘  .  ,  / and space

    • All other characters will trigger this error, including &, <, >,  and foreign numbers and characters.

  • If this file does not open within Source Viewer, please review it using tools available within your organization or supplied by your vendor. 

    • Especially look for '<' and '>' being before and after the Patient ID.  We have been informed by some EHR vendors that this may occur when a 'temporary' Patient ID has been assigned to the record within the EHR. 

    • Please contact your IT staff, EHR vendor, or vendor that supplied the software being used to generate the QRDA I documents if assistance is needed to correct this error.

• Source Viewer: None of the Measures reported in the file are from the TJC supported eMeasure list. (TJC-100003)

  • Section / Element: Measure Version Specific ID 

  • The software used to generate the QRDA I document has identified only measures not utilized by The Joint Commission. 

    • Inpatient QRDA I documents rejected by this message need to be evaluated and, if necessary, corrected by having at least one eCQM utilized by The Joint Commission identified within the document.  If corrected, the QRDA I document will need to be re-uploaded to the DDS Platform.

    • Outpatient QRDA I documents will only be identified as belonging to the Initial Patient Population of CMS' ED-3 eCQM. 

    • Given that we have asked for the same zip files which were submitted to CMS to be submit to the DDS Platform, it is appropriate for these outpatient cases to be submitted since CMS will evaluate them against their ED-3 eCQM.

    • At the same time, it is correct for the DDS Platform to reject the outpatient cases since we do not utilize this measure.  You can ignore the outpatient cases when submitting your hospital’s data.

    • When using the Submit Data page, you are only submitting the QRDA I documents associated to the measures that you select to submit. Since ED-3 is not an option, the outpatient cases will remain solely within your hospital’s DDSP Workspace and will not be submitted to The Joint Commission.

• The ‘Missing or Invalid Admission Date’ error is associated to four Source Viewer messages:

  • Source Viewer: Invalid Inpatient encounter admission date has been provided or it's before 1900. (TJC-100006)

  • Source Viewer: Inpatient encounter admission date is required. (TJC-100007)

  • Source Viewer: Inpatient encounter admission date value must be precise to the minute. (TJC-100009)

  • Source Viewer: Inpatient encounter admission date cannot be greater than current date (TJC-100010)

• Section / Element for all four Source Viewer messages: Encounter Inpatient Admit Date

• The Encounter Inpatient Admit Date is either missing or not properly formatted.  Inpatient QRDA I document rejected by this message need to be corrected by adding or updating the Admit Date.  Once corrected, the QRDA I document needs to be re-uploaded to the DDS Platform. The Inpatient Encounter Template effective-time 'low' field:

  • cannot be missing or

  • after today's date, and

  • must be reported up to minutes.

• The Joint Commission requires up to minutes. Seconds may either be present or missing; however, if present the time must be of a valid format. Valid Date/Time Format:  YYYYMMDDHHMMSSxUUUU  where

  • YYYY - year - range 1900 to 9999

  • MM - month - range 01 to 12

  • DD - day - range 01 to 31 (note: true to month and leap years)

  • HH - hour - range 0 to 23

  • MM - minutes - range 0-59

  • SS - seconds - range 0-59 x - plus or minus sign

  • UUUU - UTC time shift -1300 thru+1400

• The ‘Missing or Invalid Discharge Date’ error is associated to four Source Viewer messages:

  • Source Viewer: Inpatient encounter discharge date is missing. (TJC-100001)

  • Source Viewer: Invalid Inpatient encounter discharge date has been provided or it's before 1900. (TJC-100002)

  • Source Viewer: Inpatient encounter discharge date must be precise to the minute. (TJC-100004)

  • Source Viewer: Inpatient encounter discharge date cannot be greater than current date. (TJC-100005)

• Section / Element: Encounter Inpatient Discharge Date

• The Encounter Inpatient Discharge Date is either missing or improperly formatted.  Inpatient QRDA I document rejected by this message need to be corrected by adding or updating the Discharge Date.  Once corrected, the QRDA I document needs to be re-uploaded to the DDS Platform.

• The Inpatient Encounter Template effective-time 'high' field:

  • cannot be missing or

  • after today's date, and

  • must be reported up to minutes.

• The Joint Commission requires up to minutes. Seconds may either be present or missing; however, if present the time must be of a valid format. Valid Date/Time Format: 

  •  YYYYMMDDHHMMSSxUUUU  where

    • YYYY - year - range 1900 to 9999

    • MM - month - range 01 to 12

    • DD - day - range 01 to 31 (note: true to month and leap years)

    • HH - hour - range 0 to 23

    • MM - minutes - range 0-59

    • SS - seconds - range 0-59 x - plus or minus sign

    • UUUU - UTC time shift -1300 thru+1400

Note: At this time, The Joint Commission only utilizes inpatient measures.  Therefore, all QRDA I Documents are expected to contain a valid Inpatient Encounter with a valid Discharge Date.  Outpatient data (e.g., ED-3) will be rejected.

• Source Viewer: Invalid or null US Realm Date and Time is provided. (TJC-100035)

  • Section / Element: Header Effective Time

  • The US Realm Date and Time under <header> as given in the XPath is null or invalid.  This Date/Time is required to make the QRDA I document a valid document. Valid Date/Time Format:  YYYYMMDDHHMMSSxUUUU   where

    • YYYY - year - range 1900 to 9999

    • MM - month - range 01 to 12

    • DD - day - range 01 to 31 (note: true to month and leap years)

    • HH - hour - range 0 to 23

    • MM - minutes - range 0-59

    • SS - seconds - range 0-59 x - plus or minus sign

    • UUUU - UTC time shift -1300 thru+1400 

·         Source Viewer: There is no Inpatient Discharge Date within the reporting period in the QRDA file. (TJC-100022)

o    Section / Element: Discharge Date

o    This error is stating that the QRDA I document does not contain a Discharge Date or that the Discharge Date is not within the Reporting Period stated within the QRDA I document (i.e., calendar quarter).  Discharge Date must be equal to or before 23:59:59 local time on the final day of the calendar quarter (reporting period).

§  Inpatient QRDA I documents rejected by this message need to be corrected by adding or updating the Discharge Date.  Once corrected, the QRDA I document needs to be re-uploaded to the DDS Platform.

§  Outpatient QRDA I documents will not contain an inpatient Discharge Date.  

§  Given that we have asked for the same zip files which were submitted to CMS to be submit to the DDS Platform, it is appropriate for these outpatient cases to be submitted since CMS will evaluate them against their ED-3 eCQM.

§  At the same time, it is correct for the DDS Platform to reject the outpatient cases since we do not utilize this measure.  You can ignore the outpatient cases when submitting your hospital’s data.

§  When using the Submit Data page, you are only submitting the QRDA I document associated to the measures that you select to submit. Since ED-3 is not an option, the outpatient cases will remain solely within your hospital’s DDSP Workspace and will not be submitted to The Joint Commission.

·         Source Viewer: Inconsistent usage of time zone is found in the file.  Time zone must be used (OR not used) consistently throughout the file in all Datetime fields which contain time part. (TJC-0043)

o    Section / Element: Time zone

o    Time Zone must be consistently either be included or not be included for all Date elements that include a time stamp  (HH, HHMM, or HHMMSS).

·         Source Viewer: CCN (Facility CMS Certification Number), SHALL be six to ten characters in length (CONF:TJC-0011)

o    Section / Element: CCN

o    The hospital's Facility CMS Certification Number SHALL be six to ten characters in length.

o    The Joint Commission processes all data submitted to the DDS Platform based upon the hospital's CMS CCN, not the hospital's Joint Commission HCO ID. The Platform crosswalks the CCN back to the HCO ID for data storage and analysis purposes.

§  You can determine the CCN which The Joint Commission has linked to your HCO ID by going into HCO Characteristics (available from the main menu).  If the CCN is incorrect, please complete the Support Ticket to inform us what the correct CCN should be and we will investigate.

§  Note: We have not built the functionality to receive a file containing solely our HCO ID due to our desire to reduce hospital costs and other burden.  By receiving the file using CMS' CCN, it allows hospitals to submit the same QRDA I documents that they submit to CMS to The Joint Commission.

The CCN on file within the DDS Platform has been taken from your organization’s accreditation application - so it is possible it also needs to be updated there as well.

·         Source Viewer: Route code is missing for an administered medication, and is required by a reported eCQM. (TJC-100037)

o    Section / Element: Route Code

o    This warning indicates that a Medication Template in the QRDA file should have the medication Route information because:

§  the QRDA I document denotes that it should be processed against VTE-1 or VTE-2

§  the medication belongs to one of the below value sets used by VTE-1 or VTE-2

§  the Route Code has not been negated with negationID=true.

o    The two Medication value sets for eVTE-1 and eVTE-2 require the Route Code:

§  "Medication, Administered: Unfractionated Heparin" using "Unfractionated Heparin RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.218)"  with Attribute: "Route: Intravenous route" using "Intravenous route SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.222)"

§  Medication, Administered: Low Dose Unfractionated Heparin for VTE Prophylaxis" using "Low Dose Unfractionated Heparin for VTE Prophylaxis RXNORM Value Set (2.16.840.1.113762.1.4.1045.39)" with Attribute:"Route: Subcutaneous route" using "Subcutaneous route SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.223)

o    If you have not received the expected measure results for eVTE-1 or eVTE-2, you may update the QRDA I documents by adding the Route information, if available within the patient’s EHR, and regenerating the QRDA I documents (see below for more info). We then recommend that you Purge your data and upload the new zip file(s). To find the missing Route information:

§  In Data Accuracy tab, click on the magnifier next to the file name and it opens the Source Viewer.

§  Click on this message in the Source Viewer and the tool will take you to the correct template that is missing the <route>.

§  Compare your template with the example template from QRDA I Guide provided below.

o    Following is an example provided in HL7’s QRDA I Implementation Guide and you can see how the route is provided. Also, as given in the message description, if the <route> tag is provided, the code MUST be from value set OID=2.16.840.113883.3.88.12.3221.8.7, otherwise the document will receive an error message and will be rejected.

§  HL7 Example - Figure 67: Medication Activity (V2):
<substanceAdministration classCode="SBADM" moodCode="EVN">
<!-- ** Medication Activity (V2) ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
<id root="6c844c75-aa34-411c-b7bd-5e4a9f206e29"/>
<statusCode code="active"/>
<effectiveTime xsi:type="IVL_TS">
<low value="20120318"/>
</effectiveTime>
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
<period value="12" unit="h"/>
</effectiveTime>
<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus"
displayName="ORAL"/> 

o    Source Viewer:There exists an unacceptable unit in the QRDA document. Enter the correct unit as definied in the eCQM logic to avoid an unexpected outcome. (TJC-100039)

o    Section / Element: Result Unit

·         This warning will only trigger when incorrect/invalid unit is provided for eCQM measure logic evaluation.

·         Below are required unit as per CY2021 eCQM-

·         1) eSTK-6 - 'mg/dL' for Laboratory Test Performed

·         2) ePC-01, ePC-02, ePC-05, ePC-06 - 'wk', 'week' or 'weeks' for Assessment Performed Gestational Age calculation.

·         3) ePC-05, ePC-06 - 'g' for Assessment Performed Birth Weight calculation.

·         Source Viewer: This document SHALL contain exactly one [1..1] QDM-based QRDA document level templateId @root="2.16.840.1.113883.10.20.24.1.2" @extension="2019-12-01". QDM data elements will not be validated properly (TJC-050).

o    Section / Element: Document Level templateID

o    All valid HL7 QRDA I documents must contain one [1..1] QDM-based QRDA document level templateId @root="2.16.840.1.113883.10.20.24.1.2" @extension="2019-12-01".

o    Please contact your IT staff or vendor that supplied the software being used to generate the QRDA I documents to correct this error.

·         Source Viewer: This document SHALL contain exactly one [1..1] QRDA Category I Framework document level templateId @root="2.16.840.1.113883.10.20.24.1.1" @extension="2017-08-01". QRDA-I data elements will not be validated properly (TJC-0049).

o    Section / Element: Document Level templateID

o    All valid HL7 QRDA I documents must contain one [1..1] QRDA Category I Framework document level templateId @root="2.16.840.1.113883.10.20.24.1.1" @extension="2017-08-01".

o    Please contact your IT staff or vendor that supplied the software being used to generate the QRDA I documents to correct this error.

·         Source Viewer: This document SHALL contain exactly one [1..1] US Realm document level templateId @root="2.16.840.1.113883.10.20.22.1.1" @extension="2015-08-01". CDA data elements will not be validated properly (TJC-0048).

o    Section / Element: Document Level templateID

o    All valid HL7 QRDA I documents must contain one [1..1] US Realm document level templateId @root="2.16.840.1.113883.10.20.22.1.1" @extension="2015-08-01".

o    Please contact your IT staff or vendor that supplied the software being used to generate the QRDA I documents to correct this error.

·         Source Viewer: This effectiveTime SHALL contain exactly one [1..1] low and exactly one [1..1] high for reporting period start date and end date respectively. Reporting Period must only represent one calendar quarter with valid start and end dates within the reporting year (TJC-0007). 

o    Section / Element: Reporting Parameter

o    The Reporting Period start date must be the first day of a calendar quarter. Valid quarter start dates are: January 1, April 1, July 1 and October 1.

o    For hospital QRDA I documents, the Reporting Period end date must be the last day of the calendar quarter associated to the start date. Valid quarter end dates are: March 31, June 30, September 30 and December 31.

·         Source Viewer: effectiveTime or time SHALL have either @value or low and high but SHALL NOT have @value and low and high. (TJC-0036)

o    Section / Element: effectiveTime and time

o    effectiveTime and time elements must be properly formatted.