The Joint Commission

4. Measure Requirements: Chart and eCQM

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Topics Covered in this section:

  • Chart Abstracted Measures

  • eCQMs


CHART ABSTRACTED MEASURES

No, chart-abstracted measures are not going away in 2022 for accreditation purposes. Effective CY2021, all hospitals are required to submit ORYX Performance Measurement (eCQM and/or chart-abstracted) data for accreditation. We are aligned with CMS and continue to evaluate measures.

NOTE: The CY2022 data submission timeline is delayed. See “What’s New?” Question 1.7 for more information.

These measures remain optional for Joint Commission reporting purposes. Hospitals 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/

The DDSP Data Entry Guide will be available on our website: https://www.jointcommission.org/measurement/specification-manuals/chart-abstracted-measures/ , or copy and paste the following text into your web browser: https://www.jointcommission.org/measurement/specification-manuals/chart-abstracted-measures/

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).

  • For CY2021 eCQMs require two self-selected quarters of data; the quarters do not need to be consecutive.

  • For CY2022 eCQMs require three self-selected quarters of data; the quarters do not need to be consecutive.

  • Organizations submitting chart-abstracted PC measures may “switch” to submitting eCQM ePC 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. See “Perinatal Care” Question 6.4 for more information.

 

eCQMs


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