Large Acute Care hospitals with obstetric services are required to submit ePC-02 and ePC-07 as eCQMs, and may submit PC-06 as an eCQM or chart-abstracted measure (CAM). If submitting PC-06 as an eCQM, they must attest to this in the DDSP. Refer to the Perinatal Care Attestation topic for additional information.

Hospitals that do not provide obstetrical services have no chart-abstracted measure requirements. Additionally:  

• They may elect to submit optional chart abstracted measures if they choose.

• Hospitals that do not provide obstetrical services are not required or expected to submit "substitute" measures.

• Hospitals that do not provide obstetrical services should not enter zeros for PC/ePC measures.

Yes; Large Acute Care hospitals with obstetric services are required to submit ePC-02 and ePC-07 as eCQMs, and may submit PC-06 as an eCQM or chart-abstracted measure (CAM). If submitting PC-06 as an eCQM, they must attest to this in the DDSP. Refer to the Perinatal Care Attestation on the DDSP for additional information on how to attest to submitting PC eCQMs.

The eCQM specifications for Joint Commission only measures are available on the Measurement section of the Joint Commission's main website.

https://www.jointcommission.org/measurement/specification-manuals/electronic-clinical-quality-measures/

The ED is not considered an "obstetrical unit" so the PC measures would not be applicable. We use the hospital’s General Application/eAPP in Joint Commission Connect to determine if an organization has an obstetrical unit.

ePC-07 Severe Obstetric Complications is only available as an eCQM (specifications available on our website). There is no corresponding chart abstracted PC-07 measure.

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

• Effective 3Q2024, The Joint Commission no longer requires organizations with mid-year OB unit closures to enter zeros for the remainder of the calendar year.

•Prior Joint Commission policy required organizations to submit perinatal care data for all months they had encounters. However, effective 3Q2024, organizations are no longer required to submit partial year PC data in the event of a unit closure.

•eCQMs: Organizations should not submit PC eCQMs to The Joint Commission if they do not have a full year of data; instead, they should select and submit eCQMs applicable to their remaining patient population for the full calendar year.

•Chart-abstracted: Organizations that have entered chart-abstracted PC measures should do so through the last encounter within the quarter the unit was open, but no longer need to enter zeros the remainder of the calendar year.

•If the OB unit has closed, please updated your JC Connect eAPP, and also provide that information to us via email (HCO ORYX) or DDSP support ticket, and indicate what month the unit closed.

Applicable to CY2025:

The Joint Commission retained PC-01 and PC-05 as optional measures for accreditation.​
CMS retired PC-01 and PC-05 in CY2024.

Large Hospitals with obstetrical services are required to submit ePC-02 and ePC-07 eCQMs for both CMS and TJC. The Joint Commission also requires PC-06, and this measure may be submitted as either a chart abstracted or eCQM version of the measure for accreditation.

Specific to Certification: Performance measure requirements for the Advanced Certification in Perinatal Care (ACPC) include the chart abstracted measure PC-01, PC-02, PC-05, and PC-06.​ There are threshold requirements which must be met for the initial certification and recertification for PC-02 and PC-06. Data for certification programs are submitted into Certification Measurement Information Process (CMIP) tool.​

More information can be found on the Joint Commission Website. Accreditation - ORYX