Included in this section:

• Chart-abstracted measures

• Chart-Abstracted Measure Submission Opening and Closing Dates

• Permissions

• How to Use

Chart-Abstracted Measures

All chart-abstraction measure are managed within the DDSP. Organizations no longer need to notify The Joint Commission in advance of measure selections.

Chart-abstracted measures are selected based on ORYX requirements for your organization. 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. Measures may not be stopped/started within a calendar year, with the exception of applicable unit closures.

Standardized measure data being reported for advanced certification programs are to be reported via the Certification Measure Information Process (CMIP) tool which is available on the organization’s Joint Commission Connect site.

Chart-Abstracted Measure Submission Opening and Closing Dates

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 1.

Unless otherwise communicated, reporting chart-abstracted performance measurement data is performed quarterly*:

• 1Q (Jan, Feb, Mar) data are due by June 30th

• 2Q (Apr, May, Jun) data are due by September 30th

• 3Q (Jul, Aug, Sep) data are due by December 31st

• 4Q (Oct, Nov, Dec) data are due by March 31st

*IMPORTANT NOTE: Reporting timelines may be modified at the discretion of The Joint Commission in certain unique circumstances (e.g. as we did during the Covid-19 pandemic). Open/close dates and deadlines are shown within the platform. Keep up to date on changes to deadlines via the Timeline document. Link: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/71008257

For information on the Resubmission topic and timeframe, please see the link below.

Link: Resubmission - Joint Commission DDSP User Documentation

Permissions

Access to the Chart-Abstracted Submission module is controlled at the site level and at the user level.  If you or your facility do not have permission to access the chart-abstracted data entry tool, one of the following messages will appear when you attempt to login.

If an organization’s access is missing the following message appears:

If you have not been granted permission the following message appears:

How to Use   

Measure Selection List

The measure selection list shows the measures, if they are required, their completion status and an open button to access the data entry/submission module for the specified measure.

Open

All of the quarters for the year and their status are in a heading above the measure list. Open quarters have status ‘Closes mm/dd/yyyy’ with close date.  If Resubmission is available, the tab will show ‘Resubmission Ends on mm/dd/yyyy’. Otherwise, it is ‘Closed’ or ‘Not Yet Open’.

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

The measures and their quarter completion statuses are listed below the quarter heading.  If a measure is required or not allowed, Required -or- Not Allowed is suffixed to the measure name.  All other measures are optional.

Quarter statuses for each measure include; Not Started, In Progress and Complete. Optional measures show a dash instead of Not Started when no data as been entered for the Quarter yet.

After the data submission deadline has passed for a quarter, measures that were in the In Progress state will change to be in the Incomplete state.

Measures are greyed out if they are disabled for this facility. Please open a help ticket if a measure is incorrectly disabled or required for an organization.

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.

Continue to the next section: eCQMs

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