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To be considered for an exemption from submitting eCQM data for the current calendar year requirements, all forms must be received at The Joint Commission no later than 30 days prior to the 1Q chart-abstracted deadline. If no eCQMs will be submitted, organizations are required to submit a minimum of three (3) chart-abstracted measures for the entire calendar year*, unless the request is for an exception for submission of any data. Organizations were notified of this change to ECRs per the requirements documents provided to facilities October 2021. 

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*APPLICABLE TO CY2024: Organizations with obstetrical services and >/=300 live births, requesting an ECR for eCQMs only:

Perinatal care measures are required; organizations can meet both the PC and the ECR minimum of three (3) with obstetrical services must submit chart-abstracted measures by submitting chart-abstracted PC-0102, PC-2, PC-03, PC-0506, plus one additional chart-abstracted measure applicable to their patient population / services offered.

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*APPLICABLE TO 3Q/4Q2024: FEMA Disaster Declaration Areas for Hurricanes Francine, Helene, and Milton:

The Joint Commission has preemptively applied extenuating circumstances (i.e. no ORYX data expected or required) for all organizations in the White House / FEMA Hurricane disaster declaration area (Disaster Information | http://FEMA.gov ) for Hurricanes Francine, Helene, and Milton. Any HCO within any county listed received an ECR for all eCQM/CAM data for 3Q and 4Q2024 (7/1/2024 to 12/31/2024).

  • If your organization has been directly impacted by any of these events, no ECR form or notification to The Joint Commission is required for the specified time frame. If your facility needs to extend their exception into CY2025, please notify us via a platform support ticket or via email to HCOORYX@jointcommission.org .

  •  The FEMA list was indicated by affected county. Because the disaster declaration areas are by county, some unaffected organizations may have received an extenuating circumstance where one was unnecessary. If your organization is within a designated area but not directly impacted by any of these events and are able to submit ORYX data, please submit a platform support ticket to request the ECR be removed.

  •  Any affected organization within those designated areas can still submit data if they are able/willing to do so, even if an ECR is denoted on the DDSP. If you would like the ECR to be removed from the platform, please submit a platform support ticket to request the ECR be removed.

  • If your organization was impacted by an event outside those listed above, please complete an extenuating circumstance request form: Extenuating Circumstances

 If you have any questions, please submit a support ticket via “Need Help?” button on the DDSP or e-mail hcooryx@jointcommission.org.

Organizations required but unable to submit Chart-abstracted measures:

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Return the completed form via email to HCOORYX@jointcommission.org and include your HCO ID# or Healthcare System Name in the subject line and “Request for Extenuating Circumstances”and include the HCO ID# or Healthcare System Name, as appropriate.  

Response from The Joint Commission

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Note

Important Note: Eligible Organizations, Hospitals, and Critical Access Hospitals (CAHs) must submit a new application for any subsequent years. The Joint Commission is in alignment with CMS in that in no case may an eligible Organization, Hospital, or CAH be granted an exception for more than five consecutive years.  Organizations requesting an ECR for five or more consecutive years must provide additional supporting documentation, which may include requests/ approvals from CMS for exceptions, documentation/letter from an EHR vendor related to timeline delays, and/or any other documentation if pertinent.

Download the ECR form to your Desktop:

To access the form, click on the file preview below, then click the cloud download icon. If you are unable to download the form or are restricted by your IT security requirements, email hcooryx@jointcommission.org and request the ECR form be sent to you via reply email. ECR forms are completed then sent via email to hcooryx@jointcommission.org for review.

File previewDownloadable Microsoft form:

View file
nameExtenuating Circumstance Request Form.docx

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