Joint Commission Guide for Data Entry of Chart-Abstracted Measures for Hospitals (HAP/CAH)
- Version 2023: Discharges 01-01-2023 (1Q2023) through 12-31-2023 (4Q2023)

- Version 2024: Discharges 01-01-2024 (1Q2024) through 12-31-2024 (4Q2024); as of March 2024

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Direct Data Submission Platform (DDSP)

The Direct Data Submission Platform (DDSP) provides one place to submit both eCQM and chart-abstracted performance measurement data for accreditation purposes. The goal of the DDSP is to ease the burden and expense of data submission and empower hospitals with data for quality improvement.

The key benefits of the DDSP for chart-abstracted measure data entry includes 24/7 access during the submission period, easy to-use data visuals, a cloud-based platform environment, robust security, and transparency. Hospitals using the Platform can review their calculated results real-time as the aggregate data is being entered and the aggregate data can be updated at any time prior to the submission deadline for the quarter.

Hospitals that did not use the DDSP for submission of chart-abstracted and/or eCQM data during the previous year will need to be onboarded. Detailed instructions regarding the onboarding process will be sent in a separate communication.

How to Use the DDSP

The DDSP contains help screens, links, and “how to” videos to assist with answering frequent questions and the ability to ask The Joint Commission questions via the "Need Help?" feature on the Platform.

The Joint Commission conducts DDSP "Office Hours". Content includes tips for successful use of the DDSP and frequently asked questions. During the webinars, Joint Commission staff responsible for the DDSP are available to answer questions asked by the participants.

The “Measurement” portion of the Joint Commission website also provides ORYX FAQs accessible outside the DDSP. The ORYX FAQs provides information on wide-ranging topics related to ORYX Performance measurement.

Chart-Abstraction Measure Selections

All selections are managed within the DDSP. Hospitals and Healthcare Systems no longer need to notify The Joint Commission in advance of measure selections. Chart-abstracted measures are selected based on ORYX requirements for your hospital. Data is collected for a minimum of a calendar year to ensure that performance on a given measure is monitored over time for trends/patterns. See the Measurement > Reporting section of the external Joint Commission website for more information on chart-abstracted measure requirements for hospitals: https://www.jointcommission.org/measurement/reporting/accreditation-oryx/

Aggregate Data Entry

Hospitals aggregate and report monthly data points on chart-abstracted measures on a quarterly basis using the DDSP. 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 provided.

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

Data Entry Open and Close

DDSP users will be able to enter a month's aggregate data for chart-abstracted measures as soon as that month has completed. For example: September data can be entered starting on October 1st.

All chart-abstracted data for a specific calendar quarter needs to be submitted for that calendar quarter by the submission deadline. The submission deadlines are provided via the platform and the ORYX Performance Measurement Timeline posted within the FAQs and timeline document on the measurement / resources portion of the external Joint Commission website.

For information regarding resubmission, please see the resubmission topic: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/141295632

Quality Measure Specifications

This Guide is not intended to repeat information that is contained within the Joint Commission’s Specification Manual for Joint Commission National Quality Measures or the Center for Medicare & Medicaid Services' Hospital Outpatient Quality Reporting Specifications Manual.  Refer to the Specification Manuals for, among other items, information concerning the initial patient population, sampling requirements, measure information forms, measure algorithms, patient-level data elements, ICD, and medication code tables.

It is of primary importance that all hospitals use the appropriate version of manuals for the submission period when identifying the initial population and sample size, collecting the required patient-level data, and processing it through the algorithm for each measure. This will ensure that the data are standardized and comparable across hospitals.

This Guide will typically be updated in conjunction with the ORYX Performance Measurement reporting period and after the 1Q/2Q and 3Q/4Q releases of the Joint Commission’s Specification Manual for the given year. These releases also require CMS to have released an updated version of their outpatient specifications manual, if applicable, for the same time period.

Continue to the next section: Section 2: Aggregate Data Dictionary

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