Short Demo for PC Attestation (coming soon)
What’s in this section:
General Information about Perinatal Care Attestation
Examples
How to Attest
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General Information
For CY2021CY2022: Hospitals can attest to submitting TWO THREE 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.
For CY2022CY2023: Hospitals can attest to submitting THREE 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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May replace none, some, or all required PC measures with ePC measures.
For CY2021CY2022: 2 3 quarters of PC eCQM data = 4 quarters of the associated chart-abstracted PC measure datadata
For CY2022CY2023: 3 4 quarters of PC eCQM data = 4 quarters of the associated chart-abstracted PC measure data 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 (CY2021 2 quarters / CY2022 3 quarters) counts towards both an organization's PC requirement and eCQM requirement.
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Example 1 | 1Q | 2Q | 3Q | 4Q | Comments |
|---|---|---|---|---|---|
Chart-abstracted | Y | Y | Y | Y | HCO submits all 4 quarters of only chart-abstracted measures on all PC measures; no ePC eCQM data are used to meet the Perinatal Care requirement. |
eCQM | N | N | N | N |
Example |
|---|
1Q
2Q
3Q
4Q
Comments
Chart-abstracted
Y
Y
N
N
2 |
|---|
eCQM
N
N
Y
Y
Example 2b (CY2022) | 1Q | 2Q | 3Q | 4Q | Comments |
|---|---|---|---|---|---|
Chart-abstracted | Y | N | N | N | HCO submits first 1 quarters of chart-abstracted PC measures and last 3 quarters of ePC eCQM data; receives feedback on all data submitted. ePC eCQMs are counted toward the hospitals perinatal and eCQM requirement. |
eCQM | N | Y | Y | Y |
Example |
|---|
1Q
2Q
3Q
4Q
Comments
Chart-abstracted
N
N
N
N
HCO does not submit 1Q chart-abstracted PC measures and is required to submit 2 quarters of ePC eCQM data. ePC eCQMs are counted toward the hospitals perinatal and eCQM requirement.
eCQM
N
Y
Y
N
Example 3b 3 (CY2022) | 1Q | 2Q | 3Q | 4Q | Comments |
|---|---|---|---|---|---|
Chart-abstracted | N | N | N | N | HCO does not submit 1Q chart-abstracted PC measures and is required to submit 3 quarters of ePC eCQM data. ePC eCQMs are counted toward the hospitals perinatal and eCQM requirement. |
eCQM | N | Y | Y | Y |
Example |
|---|
1Q
2Q
3Q
4Q
Comments
Chart-abstracted
Y
Y
Y
Y
4 |
|---|
eCQM
N
Y
Y
N
HCO submits 3 ePC eCQMs for 2 quarters. ePC eCQMs are counted toward the hospitals perinatal and eCQM requirement; hospital must submit one additional eCQM.
Example 4b (CY2022) | 1Q | 2Q | 3Q | 4Q | Comments |
|---|---|---|---|---|---|
Chart-abstracted | Y | Y | Y | Y | HCO submits 1 chart-abstracted measure PC for all 4 quarters. |
eCQM | N | Y | Y | Y | HCO submits remaining 3 ePC eCQMs for 3 quarters. ePC eCQMs are counted toward the hospitals perinatal and eCQM requirement; hospital must submit one additional eCQM. |
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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.
After clicking the attest toggle, you will see the following message under the quarter tabs: “By clicking this link, you are agreeing that you will be submitting the required information via the eCQM Submission process. Are you sure you want to continue?”
If you return to the Measure List page, this chart-abstracted measure will now be shown as complete for all open quarters.
Note that while “Attest to submit via eCQM” is selected, you cannot change or remove already entered Chart-Abstracted data for that measure.
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.
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."