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THE JOINT COMMISSION & CMS

The Health Care Organization Identification number (HCO ID #) is not the same as CMS’ CCN. The HCO ID # is a unique number assigned by The Joint Commission. The Joint Commission’s HCO ID # can most easily be found when logged into your organization’s Joint Commission Connect Extranet site, shown in the upper right-hand corner, under the facility name and address.

The Joint Commission and CMS are separate entities with separate program requirements. The data is used for different purposes. There are no systems or infrastructure in place to share data between the two entities.

The Joint Commission is aligned with CMS on the requirements of reporting four quarters of eCQM data for each of four self-selected eCQMs for CY2023. The Joint Commission has 16 eCQMs available for selection. The Joint Commission offers the following additional eCQMs for selection: ePC-01, ePC-02, ePC-06, and new for CY2023 – eCQM only ePC-07. For CY 2022, CMS and The Joint Commission both utilize the chart-abstracted measure PC-01.

NOTE: The Joint Commission aligns with CMS requirements as closely as possible, however there are times when goals or program needs differ between the two entities and this necessitates variation.

The Joint Commission and CMS are separate entities. If you are not able to submit all/part of your measure requirements to The Joint Commission, you must also request an exception from TJC. Send See the “Extenuating Circumstances” section of the FAQs or send an email to hcooryx@jointcommission.org to request an Extenuating Circumstance Request (ECR) form.  (Refer to question 2.9 regarding the additional requirements and timeline of ECR requests)

Hospitals who believe they have an extenuating circumstance that would impact eCQM and/or chart-abstracted data for accreditation purposes should request an Extenuating Circumstance Request (ECR) form via email . See the “Extenuating Circumstances” section of the FAQs or send an email requesting an ECR form to: hcooryx@jointcommission.org

IMPORTANT NOTE: Hospitals required but unable to submit eCQMs must request and be granted an exception prior to the deadline to submit 1Q chart-abstracted data, as any organization unable to meet their eCQM requirement must submit three (3) chart-abstracted measures for all four (4) quarters of the calendar year.

If a hospital believes they are unable to submit chart-abstracted measures (based on their requirements or optional annual reporting) for any reason, they should submit a request for extenuating circumstances thirty (30) days prior to the quarter close of the affected quarter(s).

Chart-abstracted PC-01 is required to be reported for the CMS Hospital Inpatient Quality Reporting Program (HIQR). For The Joint Commission, any or all of the required chart-abstracted Perinatal Care Measures* (PC-01, PC-02, PC-05 and PC-06) may be submitted or alternatively, HCOs may submit all four quarters of ePC eCQM data (ePC-01, ePC-02, ePC-05 and ePC-06) instead of four quarters of the corresponding chart-abstracted measures. (Refer to Section 6: Perinatal Care for additional information)

*The new ePC-07 measure is optional and is not required.

COMMUNICATIONS

There are a few possible reasons why you may not receive ORYX email notifications:

1. ORYX email notifications are sent to the individuals documented within your hospitals Joint Commission Connect site. Notifications are primarily sent to the listed ORYX Contact, with additional notifications going to the Primary Accreditation Contact. If you are not listed as either the ORYX Contact or the Primary Accreditation Contact for your hospital, please contact on of your hospital’s Joint Commission Connect Site Administrators, as they are the only one with the authority to modify or add to your hospital’s list of contacts. Site Administrators are denoted with a small “key” next to their name in Joint Commission Connect. If you do not have access to Joint Commission Connect, contact your Quality Director.

2. If you are a listed contact (i.e., ORYX or Primary Accreditation Contact), check to see if you have opted out of receiving emails from The Joint Commission. You may have opted out in one of two ways, either by checking the opt-out box on the “Security Admin” page on Joint Commission Connect and/or you have clicked the ‘One Click Unsubscribe’ link at the bottom of an email sent by The Joint Commission. Users that have Unsubscribed from receiving e-mails and want to opt back in, should contact hcooryx@jointcommission.org for assistance.

3. If you have not opted out of receiving emails, please check your junk/spam/clutter and also check with your internal IT department and ask if your hospital is using email filtering. Hospitals using email filtering need to add Joint Commission specific domains and email addresses to ensure all communications are received.

For general Joint Commission communication, add The Joint Commission Domain to the safe sender list: @jointcommission.org

Definition: A whitelist is a list of e-mail addresses or domain names from which an e-mail blocking program will allow messages to be received. E-mail blocking programs, also called spam filters, are intended to prevent most unsolicited e-mail messages (spam) from appearing in subscriber inboxes. Depending on your email software, emails may also go to a clutter/junk/spam/other folder.  If you are uncertain how your hospital handles whitelisting, please contact your internal information technology/systems staff.

ORYX and Performance Measurement: For questions related to ORYX measure requirements, extenuating circumstance requests, and related processes, send an email to: hcooryx@jointcommission.org; be certain to include your HCO ID # in the subject line.

Chart-Abstracted Specifications: Measure questions related to Joint Commission Specifications must be submitted to the Wiki Platform: https://manual.jointcommission.org/

Joint Commission supported eCQMs / eCQM Specifications: Measure questions related to eCQM specifications should be submitted by accessing support resources available on the Joint Commission website, or copy and paste the following web address in your internet browser: https://www.jointcommission.org/measurement/specification-manuals/electronic-clinical-quality-measures/

Direct Data Submission Platform (DDSP): When logged into the DDSP, select the “Need Help?” icon and review the available topics; if you are unable to find content related to your question or issue, submit a platform support ticket via the same menu.

FEES

Organizations with ORYX requirements are invoiced in January for the upcoming calendar year of ORYX data submission based upon organizational weighted volumes for both eCQMs and chart-abstracted submissions. The ORYX annual fees are billed as a separate invoice to allow flexibility to organizations internal payment processes. Staff with access to their Joint Commission Connect site may view their invoice: Survey Process > Contracts and Billing > Fee, Billing and Invoice Information

There are no separate fees for use of the data submission platform.

DEADLINES

On Sept. 19, 2021, Apervita notified us that they would cease all business at the close of Sept. 30, 2021. As a result of their business decision, the site hosted by Apervita for direct data submission of chart-abstracted measures and/or eCQMs shut down permanently, resulting in the inability for hospitals to submit ORYX performance measurement data to The Joint Commission. Due to this, chart-abstracted and eCQM accreditation data submission timelines for 2021, 2022, and 2023 were delayed. A new Joint Commission Direct Data Submission Platform (DDSP) to collect both chart-abstracted and eCQM data was available the second half of CY2022. Hospitals submitted past 2Q2021, 3Q2021, 4Q2021 and/or eCQM ORYX data and begin CY2022 data submission based on the published timeline.

An infographic on deadlines and target dates is posted on our website under, Measurement > Resources > Supporting Materials: Website

For eCQM data, the annual submission deadline is typically March 15th of the calendar year. eCQMs may be submitted anytime between when the data submission period opens up until the deadline. As a reminder, eCQMs are currently submitted retrospectively, e.g., CY2023 eCQMs are due no later than March 15, 2024, and CY2024 eCQMs are due no later than March 17*, 2025.

*The usual deadline falls on a weekend so the date is extended to the first following business day.