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Topics Covered in this section:

  • Chart-abstracted PC measure reporting

  • eCQM PC measure reporting

 6.1: When should the HCOs communicate to TJC about the decision to submit the eCQM PC measures instead of chart-abstracted?

Hospitals must decide if they are submitting PC (chart-abstracted) or ePC (eCQM) measure data for a given measure prior to the 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.  Each measure must be Attested to individually.

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.

 6.2: If I have a large hospital with no obstetric services- do I need to submit chart abstracted measures.

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.

 6.3: Is the perinatal care eCQM required to be selected?

There are currently no specified required eCQMs. Hospitals self-select eCQMs based on their patient population/services offered.

 6.4a: If submitting all PC measures via eCQM for those 3 quarters, does that exempt chart submission for the entire year or just those three quarters?

For the PC measures:

  • CY2021: 2 quarters of eCQM data = 4 quarters of chart-abstracted measure data

  • CY2022: 3 quarters of eCQM data = 4 quarters of chart-abstracted measure data

  • CY2023: 4 quarters of eCQM data = 4 quarters of chart-abstracted measure data

  • Submission of annual eCQM ePC data exempts the hospitals from submitting any chart-abstracted data for the associated PC measures, e.g. if an HCO submits all required PC measures as eCQMs, no additional eCQMs are required.

 6.4b: If we submit all four perinatal care measures as eCQMs for all 3 quarters for CY2022, do we also have to submit four additional eCQMs?

No - additional eCQMs are not required if all four required PC measures are submitted as eCQMs, (although they 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, e.g. if an HCO submits all required PC measures as eCQMs, no chart-abstracted measures are required.

Organizations are strongly encouraged to “attest” to submitting perinatal care eCQMs instead of chart-abstracted perinatal care measures within the chart-abstracted measure module.

TIP: Be certain you are able to submit eCQM PC data before the first chart-abstracted measure deadline.

 6.5: Where are the specifications for the ePC-01 and ePC-02 as they are not listed on the eCQI resource center?

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/

 6.6: Is the number of live births calculated from the previous calendar or fiscal year of the organization?

The number of lives births is based on the prior calendar year 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.

 6.7: 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?

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.

 6.8: If a hospital does not have OB services however has had deliveries in the ED do those numbers count?

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 you have an obstetrical unit.

 6.9: Will PC-07 be a chart abstracted measure?

ePC-07 Severe Obstetric Complications was added as a new Joint Commission only eCQM (specifications available by January 2022). 

There is no corresponding chart abstracted PC-07 measure. This measure is not required for 2022 collection but is offered as an optional measure to meet ORYX eCQM requirements.

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