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Data prior to CY2023 cannot be resubmitted. Information regarding resubmission of CY2023 data and beyond is pending. Effective CY2023 data, chart-abstracted measures can be resubmitted if an organization identifies errors in previously entered data. For more information on resubmission, see the Resubmission help topic: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/141295632

The DDSP will accept the same QRDA I documents that are submitted to CMS (with the exception of measures not currently supported by CMS).For CY2023 ORYX purposes, ePC-01 (Elective Delivery) has been retained and ePC-02 (Cesarean Birth) has been adopted as ORYX measures.

Links to the eCQM specifications, measure flows, value sets, and technical release notes for both measures are available at: https://www.jointcommission.org/measurement/specification-manuals/electronic-clinical-quality-measures/

As a reminder, the specifications and supporting information for eCQMs used by both The Joint Commission and the Centers for Medicare & Medicaid Services (CMS), are available from the eCQI Resource Center or by clicking copying and pasting the web address into your internet browser: https://ecqi.healthit.gov/qrda  (Make sure to select the appropriate Reporting Period).

The Joint Commission will be accepting the same QRDA I documents as CMS.  These are the files that EHR/HIT vendors are certified by ONC for quality measurement purposes.

QRDA I documents are not de-identified.

The Joint Commission's process is to anonymize the data being stored within our database.  This means that only the PHI data which is required to calculate the eCQMs (e.g., Admission and Discharge Dates).is stored.

Note: PHI data should not be included in the file names being uploaded to the DDSP.

Joint Commission's requirements state organizations should only select measures applicable to the services provided and patient populations served. A HCO can still meet the intent of the ORYX requirement if at least one patient is in the initial population for each measure submitted.

For eCQMs: The Joint Commission is aligned with CMS with allowing attestation for zero denominators in a measure or, if desired, invoking the case threshold exemption (five or fewer cases in the denominator).

When submitting eCQM data via the DDSP:

• Zero Cases: a checkmark indicates a HCO's attestation of having zero patients/cases that fit the denominator criteria for the calendar quarter.

• Threshold Exemption: a checkmark indicates the HCOis submitting this measure to The Joint Commission; however, they are invoking the exemption to not submit the associated patient-level data because they have five or fewer cases that fit the denominator criteria for the calendar quarter.

• Zero Cases in IP: a checkmark indicates "No cases are in the Initial Population (IP) of the measure; however, my HCO has certified EHR software capable of generating QRDA I documents for the measure."

NOTE: For submission of eCQMs to The Joint Commission, it is appropriate if the "self-selected calendar quarters" to be submitted is by measure; meaning that the HCO submits eCQMs, but not necessarily all eCQMs are submitted for the same quarter.

For chart-abstracted measures: The Joint Commission is aligned with CMS with allowing attestation for zero denominators in a measure.

When submitting chart-abstracted data via the DDSP:

• Zero Cases Initial Population: if a zero (0) is entered into the Initial Population field for a month, the user is prompted to attest that the HCO had zero patients/cases that fit the Initial Population of the measure for the month. This attestation is to support HCOs which may not have a patient in the initial population every month and psychiatric hospitals which only provide services to children or adults.

• Zero Cases: if a zero (0) is entered into the Denominator (proportion/ratio measures) or Population (continuous variable measures) field, the user is prompted to attest that the HCO had zero patients/cases that fit the denominator criteria for the month.

NOTE: The exemption for not submitting patient-level data when the organization has five or fewer discharges that fit the denominator criteria for the calendar quarter is no longer applicable for Joint Commission chart-abstracted measures as HCOs are only submitting aggregate data. There is no exemption for chart-abstracted measures as it relates to certified EHR software.