Short Demo (coming soon) for Chart-Abstracted Data Entry, Submission, and Status

Table of Contents:

• Purpose

• Reference Material

• Aggregate Data Entry

• How to Use

  • Accessing the data entry tool

  • Chart-Abstracted Measure Submission’ data entry tool

  • Switch hospital or measure

  • Select a quarter

  • View and Edit data

  • Error Messages

  • Zero attestation of the Initial Population or Denominator

  • View Submission Status

Purpose

When selecting ‘Chart-Abstracted Measure Submission' from the menu, the ‘Chart-Abstracted Measure Submission’ page becomes available displaying the list of chart-abstracted measures. Access to the 'Chart-Abstracted Measure Submission’ data entry tool for each measure is available from this page.

The Chart-Abstracted Measure Submission data entry tool is for entering aggregate Chart-Abstracted data. This page describes how to:

• see if you have permission to enter data in the tool

• navigate within the tool, switch between hospitals, measures, quarters

• check submissions

Reference Material

The Joint Commission Guide for Data Entry of Chart-Abstracted Measures  is posted on The Joint Commission Website. This guide defines the aggregate chart-abstracted accreditation measure data to be entered into the DDSP data entry tool.

The Specification Manuals describe the chart-abstracted measures and data. The Specification Manuals contain the measure algorithm flows and data element definitions. These aid in understanding the measures and the data that is aggregated for the Chart-Abstracted Measure data entry tool.

Within the data entry tool, information icons provide information about each data field. Hover the cursor over the information icon to see information, such as the definition of the data that has been abstracted and aggregated.

Aggregate Data Entry

HCOs aggregate and report monthly data points on chart-abstracted measures on a quarterly basis beginning with 1Q2020 data using the DDS Platform.  No patient level data is submitted.

It is expected that hospitals will ensure the accuracy and completeness of the patient-level data processed through each measure’s algorithm and will validate that the derived aggregated data represents the care actually provided.

The DDSP will validate the entered aggregate data by performing consistency and edit checks to assure the integrity of the submitted aggregate data.

Hospitals can attest to submitting two 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. The Perinatal Care Attestation Topic provides additional information.

How to Use   

Accessing the data entry tool

The Measure Selection list shows the measures. For each measure, the list shows whether it is required or not available for data entry, each measure’s completion status by quarter and an open button. In addition, the list shows which quarters are open for data entry and, for those open, what each quarter’s submission deadline (close date) is.

a measure by clicking the Open button in the Measure List on the right. PC-01 measure was opened. This opens the data entry tool for the selected measure.

Chart-Abstracted Measure Submission’ data entry tool

Note: Data may be changed up until the close of the quarter. After the quarter deadline there is no resubmission of data and the quarter will be shown as closed on the form.

Switch hospital or measure

Switch to another hospital or measure from the top of the measure data entry screen:

• The hospital and a dropdown hospital selection list (to switch hospitals) is in the top left corner.

• Below the Need Help? button, there are two ways to switch to a different measure; either from ‘Return to Measure List’ or by directly choosing a measure from the list box next to it.

Select a quarter

Note: If a measure is not available for certain quarters then no form will be available. An example of this is the influenza immunization which does not accept data for quarters 2 and 3.

Quarters are displayed in tabs above the data fields. The First Quarter tab is automatically selected. If a quarter is open, its status will be ‘Closes mm/dd/yyyy’. Otherwise it is ‘Closed’ or ‘Not Yet Open’. Click on the quarter tab to view or change its data.

Select a quarter by clicking one of the quarter tabs.

View and Edit data

Note: The minimum amount of data that can be entered and saved per data entry session for a measure is a complete month.

The Edit/Done buttons and statuses in the upper right corner of the screen are summarized below. Different messages and buttons appear as data is entered, checked for errors, and then saved and submitted.

1. To add or change data, click on ‘Edit quarter values’.

1. No changes detected and ‘Done’ is greyed out.

1. Changes detected and ‘

Done' enabled. Click ‘Done’ to save. If no errors, ‘Edit quarter values’ (0) appears and data is saved. Else ‘Error’ (3).

1. Error found. Correct the errors click ‘Done’ again. If data passes, Edit quarter values’ reappears.

Next click on 'Edit quarter values’, on the far right of the screen below the quarter tabs. This changes the screen from View mode to Edit mode and enables data entry.

Note: You must enter the whole month’s data, without error, before you can save. Scroll down the entire page to find the error messages.

Note: Entered and saved numeric data may be changed or cleared, before the close of quarter. If the intent is to delete the entire month of data, be sure to clear all of the numeric entered data.  Clear the entered numeric data by either backspacing through the number, or highlight the number and hit the Delete key.

‘Edit quarter values’ changes to ‘Done’. Now data can be entered.

‘Done’ becomes active when changes are detected. Click ‘Done’ when ready to save changes.

Error Messages

All fields must have values and pass validation before data is saved. Error messages appear under any fields that failed validation. The ‘Done’ button changes to ‘Error’.

If the Done button does not switch back to view mode (Edit quarter values) after you click it, remember to scroll down to check all of the data for errors.

Each field has an i information icon that provide useful information when the cursor hovers over it. The information summarizes data definition and requirements. This helps to explain validation errors.

Zero attestation of the Initial Population or Denominator

If zero is entered for Initial Population or Denominator, zero attestation is required before saving. A zero attestation box appears and must be checked. After the box is checked, some data fields are deactivated.

Calculated values have a blue background with white text. Click ‘Done’ to check the entered data. If the entered data passes all of the rules, the remaining fields are calculated and the data is saved.

View Submission Status

To view the status of data entry you can click on the i icon next to the hospital name. From there you can ‘Download Submission Report’. You can also return to the Welcome Page and click on ‘Download Report’ for the hospitals that you have permission for.