No, chart-abstracted measures are not going away for accreditation purposes. Effective CY2021, all Joint Commission accredited organizations with ORYX Performance Measurement requirements are required to submit (eCQM and/or chart-abstracted) data. Chart-abstracted measures remain required for Freestanding Psychiatric Hospitals and Assisted Living Communities.

These measures remain optional for Joint Commission reporting purposes. HCOs may elect to submit these measure, or Small/Critical Hospitals may submit these measures to meet their reporting requirements. Please refer to the full list of available measures available on our website, or copy and paste the following text into your web browser: https://www.jointcommission.org/measurement/reporting/accreditation-oryx/

As a supplement to measure specifications, The Joint Commission provides a Guide for Data Entry of Chart-Abstracted Measures which describes the aggregate data requirements for organizations submitting chart-abstracted measure data. This is available within these help content pages, and a link is also available on the Measurement>Specifications part of our external website, or copy and paste the following web address in your internet browser: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/112001025

The DDSP Data Entry Guide is typically available in during the first quarter of the reporting year and available within the help content: (HAP/CAH) Joint Commission Guide for Data Entry of Chart-Abstracted Measures for Hospitals or by copying and pasting the url into your web browser: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/112001025

Currently, there are no plans to provide upload capability of data for chart-abstracted measures.

• Chart-abstracted measures require the entire calendar year to be submitted (all 4 quarters) unless they are seasonal measures (e.g., IMM-2).

• eCQMs require four quarters of data be submitted unless otherwise noted in the ORYX Performance Measurement Reporting Requirements measure list for the applicable calendar year.

• Organizations submitting chart-abstracted PC-06 measure may elect to submit eCQM ePC-06 measures instead. To meet the PC requirement, organizations must submit either all four quarters as a chart-abstracted PC measure, or submitting the corresponding ePC measure based on the above annual requirements. If submitting ePC-06 as an eCQM, perinatal care attestation is required.

Yes - Organizations have the option of submitting any additional measures - chart-abstracted and/or eCQMs. Organizations will receive feedback/comparative data for any measures submitted.

The Joint Commission Guide for Data Entry of Chart-Abstracted Measures describes the aggregate data requirements for facilities submitting chart-abstracted measure data. The information in the Guide is intended to assist health care organizations in their preparation for data entry of their aggregate data into the Joint Commission’s Direct Data Submission Platform (DDSP).

The Joint Commission Guide for Data Entry of Chart-Abstracted Measures is available on our website, or copy and paste the following web address in your internet browser: https://www.jointcommission.org/measurement/specification-manuals/chart-abstracted-measures/

No - Don’t enter zeros for measures you’re not submitting data for; only enter data for measures your organization is required and/or electing to submit.

• This includes the PC measures for those organizations that do not provide OB services

For Joint Commission reporting purposes, when determining the patient population to be included and sampled (using the Global Sampling specifications), all applicable inpatients from across the accredited HCO must be included regardless of location, setting of care, and/or payment source.

HCOs submitting HBIPS, TOB, SUB and/or IMM measures must implement the Joint Commission’s sampling requirements. CMS accepts the Joint Commission’s sampling requirements for their Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program.

For additional information, see the Sampling section of the Specifications Manual for Joint Commission National Quality Measures  Specifications Manuals

Chart-abstracted data are due quarterly*, reporting monthly, aggregate data points for each quarter via the new Direct Data Submission platform.

*Organizations electing to submit SDOH measure(s) submit all four quarters of data in line with the 4Q chart-abstracted deadline.

Please see the “ORYX Performance Measurement Timeline” documentation for key dates and information or copy and paste the following link text into your web browser: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/71008257/ORYX+Performance+Measurement+Timeline

HCOs collect and report monthly data points on chart-abstracted aggregate data (e.g., numerator, denominator, etc.) on a quarterly basis and enter that data for those measures using the DDSP.  No patient level data is submitted.  HCOs submit numerator and denominator data by month, with a few additional data points including inpatient population (IPP) and exclusions (as needed by measure). Refer to the: Joint Commission Guide for Data Entry of Chart-Abstracted Measures

As with the chart-abstracted measures, selections should be based on populations and services provided. If an HCO does not provide a service(s) addressed by certain eCQMs such that the HCO is unable to identify four applicable eCQMs, then the HCO would report on only those eCQMs for which it has the relevant patient population/service. HCOs should not select eCQMs for which it has no patient population and would be reporting zero values.

Important Note: HCOs unable to meet the eCQM requirement and are granted an extenuating circumstance by The Joint Commission must substitute chart-abstracted measure(s) and submit those chart-abstracted measures for all four quarters of the calendar year in accordance with the standard data submission timeline.

Additional information will be provided on our website regarding eligibility for recognition. See the “Pioneers in Quality” section of our website for additional information: Pioneers in Quality

Joint Commission requires reporting four quarters (Q) of data (1Q, 2Q, 3Q, 4Q)*. The same eCQMs must be submitted for all four quarters submitted. The Joint Commission and CMS do not share data and there is no requirement to submit the same measures/quarters to each entity. For eCQMs, the measures being submitted are at the discretion of the HCO but must reflect patient population/services offered.

*Exception: For CY2025, in alignment with CMS, if eOP-40 is reported, only two (2) self-selected quarters are required and will count as a complete measure / towards meeting the eCQM requirement.

QRDA I documents for eCQM data may be uploaded when The Joint Commission opens the eCQM module for the calendar year, typically during the second quarter. QRDA I documents for eCQM data may be submitted as soon as The Joint Commission makes the platform available for submission of that calendar year’s eCQMs (typically early January of the following calendar year). To submit data, the entire calendar quarter must be available. eCQM data is submitted retroactively.

Please see the “ORYX Performance Measurement Timeline” documentation for key dates and information: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/71008257/ORYX+Performance+Measurement+Timeline

eCQMs are due at The Joint Commission no later than the annual deadline date. HCOs may upload their eCQM data on a quarterly basis; however, the submission deadline is the same for all quarters of eCQM data submitted.

Please see the “ORYX Performance Measurement Timeline” documentation for key dates and information.

https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/71008257/ORYX+Performance+Measurement+Timeline