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Joint Commission's requirements state hospitals should only select measures applicable to the services provided and patient populations served. A hospital 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 hospital is 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 hospital 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 hospitals 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 hospital 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 hospitals are only submitting aggregate data. There is no exemption for chart-abstracted measures as it relates to certified EHR software.