Topics Covered in this section:

• Verifying ORYX Requirements via HCO Characteristics

• Chart-abstracted data - verifying data is submitted and Submission Report

• eCQM data - verifying data is submitted and Submission Report

1. ORYX Requirements are determined by organization type, service, and volume

• HCO Characteristics references information from organization's Joint Commission Connect site > General Application to determine ORYX requirements.

• To view how your organizational requirements are categorized on the DDSP, select “HCO Characteristics” from the menu.

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2. Verify your program and organization type to determine your ORYX requirements

• If the information on the DDSP needs to be updated, submit a support ticket via the “Need Help?” button

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3. There are currently 3 programs (ALC, CAH, HAP) and 3 sub types of HAP¹ (Large, Small, Psych) with ORYX requirements:

1 Organizations can have multiple program types, e.g., both HAP and CAH
2 HAP Large requirements are further determined by obstetrical services

4. ORYX requirements are posted on the external Joint Commission website under both “Reporting” and “Resources”:

5. Use the information (updated annually) to determine what the annual requirements & available measures are for your organization

6. For those organizations with specific required measures, those measures will be indicated in blue italic text as: ”(Required)”.

• If an organization submits an optional measure for the first calendar quarter, that measure becomes required for the full calendar year; organizations may not stop/start measures mid-year with the exception of unit closures (i.e. closure of an obstetrical unit).

• When chart-abstracted data is submitted, the measure will show as “Complete”.

• When chart-abstracted data is entered for some months of a quarter, the measure will show as “In Progress”.

• When a chart-abstracted data is not entered for a required measure, it will show as “Not Started”.

• Any measure showing as “Not started” or “In Progress” is not submitted and the requirement is not met.

7. The Home Page Chart-abstracted Submission status:

a) Indicates the status of the currently displayed HCO.

b) The status for all HCOs the user has access to is displayed when selecting “Open” from the home page chart-abstracted measure submission status section.

c) The Chart-abstracted measure Submission report for each HCO the user has access to should be downloaded by selecting the text, “Download Submission Report”.

8. The Home Page Submission status for HCOs not submitting Chart-Abstracted Measures

• Chart Abstracted Status 1Q(Year) Not Started – if an organization is not required or electing to submit optional chart-abstracted measures, or are submitting eCQMs to meet their ORYX requirements, this status can be ignored.

9. The Joint Commission’s DDSP Support Staff and HCO ORYX email staff are not able to individually verify submission status.

• All organizations, including those using a vendor / or consultant, are responsible for verifying their data is submitted on time, correctly, and as expected prior to established deadlines.

• Users with access to the DDSP should download the submission report from the DDSP homepage as verification / proof of submission and verify the report reflects the data submitted.

10. Upload, Validate, Verify eCQM Data prior to submission.

• Upload QRDA data for the applicable year via the eCQM Upload Data page and verify the upload by checking the Upload Summary tab

• After receiving the upload success message on the upload page, it might take up to 48 hours to see the results in Data Accuracy and the Quality Improvement (QI) page

• Set the notification in User Settings to be notified when your uploaded data has processed and is ready for review.

11. eCQM Data Submission; upload and review your data and verify the measure outcomes prior to data submission. When ready to submit:

a) Select each quarter you plan to submit

b) Select each measures you intend to submit

c) Select an attestation box if applicable

Then scroll to the bottom of the page and select “Submit” and Confirm Submission.

d) When you submit data, attestation boxes are validated

e) You will be provided a description of ORYX requirements for your Facility to ensure you are meeting the requirements

f) You can submit data and withdraw the submitted data until the deadline to correct any data issues.

12. eCQM Submission Report

• After data has been submitted, a banner indicating that data has been successfully submitted will remain at the top of the eCQM submission page.

• Users should download the submission report at the bottom of the page as proof of submission

• Verify the report reflects the data submitted

13. Home Page eCQM Submission status should indicate “Submitted” and the Submission Report is available to download.

a) Indicates the status of the currently displayed HCO.

b) The status for all HCOs the user has access to is displayed when selecting “Open” from the home page eCQM measure submission status section.

c) The eCQM measure Submission report for each HCO the user has access to should be downloaded by selecting the text, “Download Submission Report”.

End of Topic Section