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.

As a supplement to measure specifications, 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).

• eCQMs require four quarters of data be submitted.

• 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.

Small Acute Care Hospitals and Critical Access hospitals with obstetrical services can elect to submit perinatal care data if they choose.

Large Acute Care Hospitals with obstetrical services can elect to submit PC-08 (eCQM): Timely Treatment of Severe Hypertension.

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 organizations required to submit chart-abstracted measure data, data is due quarterly, reporting monthly, aggregate data points for each quarter via the Direct Data Submission platform.

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

ALCs and separately accredited Freestanding Psychiatric Hospitals 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

Organizations required but unable to submit eCQMs should submit an extenuating circumstance request (ECR) to Joint Commission detailing your circumstances. Effective CY2026, organizations granted an exception for submission of eCQMs will not be required to submit “substitute” chart-abstracted measures.

Important Note: HCOs unable to meet the eCQM requirement must submit an extenuating circumstance to Joint Commission.

Joint Commission requires reporting four quarters (Q) of eCQM data (1Q, 2Q, 3Q, 4Q).

QRDA I documents for eCQM data may be uploaded when 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 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 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