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Chart-abstracted PC measure reporting
eCQM PC measure reporting
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| title | 6.1a: APPLICABLE TO CY20231: When should the HCOs communicate to TJC about the decision to submit the eCQM PC measures instead of chart-abstracted? |
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| Hospitals must decide if they are submitting PC (chart-abstracted) or ePC (eCQM) measure data for a given measure prior to the 1Q chart-abstracted submission deadline. Hospitals may elect to submit all chart-abstracted measures quarterly, all eCQMs for the required number of quarters annually per the reporting requirements, or combination of both. For example, an organization may elect to submit PC-01 and PC-02 as eCQMs, but still submit PC-05 and PC-06 as chart-abstracted measures. To notify The Joint Commission that a measure will be submit as an eCQM, the HCO will Attest via the Chart-Abstracted Data Submission module within the platform. Each measure must be Attested to individually. | IMPORTANT NOTE: If the Attestation is made too early and the hospital discovers they are unable to submit their eCQM data by the annual deadline, they will not have met their ORYX Requirements for the year because the aggregate data was not submitted. For this reason, The Joint Commission strongly suggests the chart-abstracted data is submitted until the hospital is certain the eCQM data can be successfully submitted.
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| title | 6.1b: APPLICABLE TO CY2024: When should the HCOs communicate to TJC about the decision to submit the eCQM PC measures instead of chart-abstracted? |
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Effective 1/1/2024 patient discharges and applicable to CY2024 ORYX Requirements, Large Acute Care hospitals with obstetric services are required to submit ePC-02 and ePC-07 as eCQMs, and may submit PC-06 as an eCQM or chart-abstracted measure (CAM). If submitting PC-06 as an eCQM, they must attest to this in the DDSP. |
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| title | 6.2: If I have a large hospital with no obstetric services, do I need to submit chart abstracted measures? |
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Hospitals that do not provide obstetrical services have no chart-abstracted measure requirements. Additionally: They may elect to submit optional chart abstracted measures if they choose. Hospitals that do not provide obstetrical services are not required or expected to submit "substitute" measures. Hospitals that do not provide obstetrical services should not enter zeros for PC/ePC measures.
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| title | 6.3a: APPLICABLE TO CY2023: Are there any specific perinatal care eCQMs required to be selected for 2023? |
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| No; For CY2023, there are no specified required eCQMs | The Joint Commission. Hospitals required or electing to submit eCQMs self-select eCQMs based on their patient population/services offered.
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| title | 6.3a: APPLICABLE TO CY2024: Are there any specific perinatal eCQMs required to be selected for 2024? |
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Yes; Effective 1/1/2024 patient discharges and applicable to CY2024 ORYX Requirements, Large Acute Care hospitals with obstetric services are required to submit ePC-02 and ePC-07 as eCQMs, and may submit PC-06 as an eCQM or chart-abstracted measure (CAM). If submitting PC-06 as an eCQM, they must attest to this in the DDSP. Refer to the Perinatal Care Attestation on the DDSPfor additional information on how to attest to submitting PC eCQMs. |
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| title | 6.4a: APPLICABLE TO CY2023: If submitting all PC measures via eCQM, does that exempt chart submission for the entire year or just those quarters? |
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For the PC measures: For CY2023, 4 quarters of eCQM ePC data = 4 quarters of chart-abstracted PC measure data Submission of annual eCQM ePC data exempts the hospitals from submitting any chart-abstracted data for the associated PC measures. If an HCO submits all four required ePC measures as eCQMs, no additional eCQMs are required, as they have met both the perinatal care requirement and the eCQM requirement by submitting ePC data (see Question 6.4b).
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| title | 6.4b: APPLICABLE TO CY2023: If we submit all four perinatal care measures as eCQMs do we also have to submit four additional eCQMs? |
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For CY2023, additional eCQMs are not required if all four required PC measures are submitted as eCQMs, (although hospitals may submit additional eCQMs if they choose).
Large acute care hospitals providing obstetrical services are required to submit PC data and can meet both their eCQM AND PC requirement by submitting ePC-01, ePC-02, ePC-05, ePC-06.
Also note submission of annual eCQM ePC data exempts the hospitals from submitting any chart-abstracted data for the associated PC measures. If an HCO submits all required PC measures as eCQMs, no chart-abstracted measures are required.
Hospitals submitting eCQM ePC measures must “attest” to submitting the corresponding chart-abstracted perinatal care measure(s) within the chart-abstracted module.
IMPORTANT: Be certain you are able to submit eCQM PC data before the first chart-abstracted measure deadline.
Refer to Perinatal Care Attestation on the DDSPfor additional information on submitting eCQM PC measures instead of chart-abstracted PC measures. | Expand |
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| title | 6.5: Where are the specifications for the ePC-01 as they are not listed on the eCQI resource center? |
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The eCQM specifications for Joint Commission only measures are available on the Measurement section of the Joint Commission's main website. https://www.jointcommission.org/measurement/specification-manuals/electronic-clinical-quality-measures/ |
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| title | 6.6: APPLICABLE TO CY2023: Is the number of live births calculated from the previous calendar or fiscal year of the organization? |
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Applicable to 2023: The number of lives births is based on the prior two calendar years (see 6.7b) and should match what is shown in the eAPP within Joint Commission Connect. If an organization’s PC volumes change during the current calendar year of reporting, it does not impact their PC requirement for the current year. |
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| title | 6.7a: APPLICABLE TO CY2023: If we are an Acute Care Hospital but do not have 300 births per year, would we still be expected to submit all Perinatal measures for chart abstracted? |
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Applicable to 2023: Hospitals that provide obstetrical services and have between 1-299 live births annually are required to submit ePC-01 or PC-01; they may submit additional ePC / PC measures if they choose. |
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| title | 6.7b: APPLICABLE TO CY2023: How do we determine if we meet the PC measure threshold? |
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For CY2023: the threshold for mandatory reporting of the Perinatal Care (PC) performance measures is ≥300 births per year. This threshold means that all Joint Commission accredited hospitals with 300 or more births per year are required to collect data and report on all applicable/available chart-abstracted* PC measures.
Hospitals can determine if they meet the threshold for the required use of the PC measures by calculating the average number of births for the two most recent calendar years (CY) for which there are complete data. If the average number of births is at least 300, then data collection on the PC measures is required.
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*Refer to Perinatal Care Attestation on the DDSPfor additional information on submitting eCQM PC measures instead of chart-abstracted PC measures. Refer to the applicable reporting year measure requirements on the measurement section of the Joint Commission Website for the list of available/applicable PC measures. Calculation of Average Number of Births |
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Calendar Year (CY) | Total Births | CY 2021 | 270 |
CY 2022 | 352 |
CY 2021 + CY 2022 | 612 |
Average** number of Births | 612 divided by 2 = | 306 |
**For the purposes of calculating the average number of births, organizations should count the number of actual live births rather than the number of deliveries. (In the case of triplets, for example, one delivery results in three births.) |
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| title | 6.8: If a hospital does not have OB services however has had deliveries in the ED do those numbers count? |
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The ED is not considered an "obstetrical unit" so the PC measures would not be applicable. We use the hospital’s General Application/eAPP in Joint Commission Connect to determine if an organization has an obstetrical unit. |
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| title | 6.10: If we do not provide OB services, do we enter zeros in the DDSP for the measures? |
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Don’t enter zeros for measures you’re not submitting data for*; only enter data for measures your organization is required and/or electing to submit. This includes the PC measures for those organizations that do not provide OB services *If your OB unit closed mid-year, do enter zeros to complete the quarter and all remaining quarters for that calendar year.
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| title | 6.11 For CY2024, what What PC measures are available? |
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Applicable to CY2024: The Joint Commission has retained PC-01 and PC-05 as optional measures for accreditation.
CMS has retired PC-01 and PC-05 for CY2024. Effective 1/1/2024, Large Hospitals with obstetrical services are required to submit ePC-02 and ePC-07 eCQMs for both CMS and TJC. The Joint Commission also requires PC-06, and this measure may be submitted as either a chart abstracted or eCQM version of the measure for accreditation. Specific to Certification: Performance measure requirements for the Advanced Certification in Perinatal Care (ACPC) include the chart abstracted measure PC-01, PC-02, PC-05, and PC-06. There are threshold requirements which must be met for the initial certification and recertification for PC-02 and PC-06. Data for certification programs are submitted into Certification Measurement Information Process (CMIP) tool. More information can be found on the Joint Commission Website. https://www.jointcommission.org/measurement/reporting/accreditation-oryx/ Name | Chart-Abstracted Measure (CAM) | Electronic Clinical Quality Measure (eCQM) | Accreditation (Large Hospitals w/OB Services) | Used in CMS Program |
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Elective Delivery | PC-01 optional | ePC-01 optional | TJC not required; available as an optional measure | PC-01 - Retired from CMS in 2024 | Cesarean Birth | PC-02 optional | ePC-02 required | eCQM ePC-02 is required for CY2024 | ePC-02 | Exclusive Human Milk Feeding | PC-05 optional | ePC-05 optional | TJC not required; available as an optional measure | ePC-05 - Retired from CMS in 2024 | Unexpected Complications in Term Newborns | PC-06 see note | ePC-06 see note | NOTE: Required for CY2024; may be submitted as CAM or eCQM | n/a | Severe Obstetric Complications | n/a | ePC-07 required | ePC-07 | ePC-07 |
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