1Q certification data is due June 30th
2Q certification data is due September 30th
3Q certification data is due December 31st
4Q certification data is due March 31st

Acute Stroke Ready Hospital (ASRH)
Comprehensive Stroke Care (CSC)
Primary Stroke Center (PSC)
Thrombectomy Capable Stroke Center (TSC)
Acute Heart Attack Ready (AHAR)
Comprehensive Cardiac Care Centers (CCCC)
Heart Failure (HF)
Primary Heart Attack Center (PHAC)
Health Care Staffing Services (HCSS)
Total Hip and Knee Replacement (THKR)
Palliative Care (PC)
Perinatal Care Certification (PCC)
Spine Surgery (ACSS)

For organization applying for Certification programs that do not have standardized measures, your
hospital is required to report on four self-selected Performance Measures. At least two of the four
measures should be clinical measures related to or identified in clinical practice guidelines for that
program or service. Measures selected by the program or service should be evidence-based, relevant,
valid and reliable. Certification data is entered into the Certification Measure Information Process (CMIP)
application (available via Joint Commission Connect® site). The Data Submission tab allows your
organization to record and track the data entered for each program.

Effective 1/1/2020, The Joint Commission no longer has contracts with ORYX chart-abstracted vendors
for certification or accreditation purposes. If available, a healthcare organization may use a vendor tool
to identify numerator and denominator values for entry in the Certification Measure Information Process
(CMIP) application on its Joint Commission Connect® secure-extranet site; however, the healthcare
organization must self-submit these data each month via CMIP to meet certification measure reporting
requirements.

Effective 1/1/2020, The Joint Commission no longer has contracts with ORYX chart-abstracted vendors
for certification or accreditation purposes.

Effective 1/1/2020 patient discharges, all hospitals in the Perinatal Care (PNC) certification program
that have been using an ORYX chart-abstracted vendor must manually enter their aggregate data on the
Certification Measure Information Process (CMIP) application available on JC Connect. Hospitals may
use a vendor to assist in data collection and aggregation.

Note: For reporting of the chart-abstracted PC measures for ORYX accreditation reporting purposes,
hospitals submit data via the The Joint Commission’s Direct Data Submission Platform (DDSP).

Certification data is entered into the Certification Measure Information Process (CMIP) application
(available via Joint Commission Connect® site).

• The following documents contain information about how to enter data into CMIP:
  "Completing Certification Measure Information Process (CMIP)" with the Certification tab when
  logged into your organizations Joint Commission Connect® site, under “Continuous
  Compliance” > “Certification Measurement Information Process” > “Resources”

• Additional information on the Advanced Certification Program standardized measures are in the
  Specifications Manual for Joint Commission National Quality Measures on The Joint
  Commission website.

• See the Specifications section of our The Joint Commission external website, or
  copy and paste the following web address in your internet browser: https://www.jointcommission.org/measurement/specification-manuals/chart-abstracted-measures/

Starting January 1, 2021, health care organizations with more than one site with the same certification,
must choose the specific site for when submitting certification data.

A new feature has been added to CMIP beginning January 2021. If a health care organization has zero
cases to report for a specific month for a measure, the organization may enter “zero” directly in the
CMIP data entry fields without any warning or error messages.
A zero-attestation check box has been added to each data point to confirm the health care
organization’s intention to submit zero cases for a respective month

Based on the current date, the data for the previous 24 months can be entered/modified.
Data older than 24 months will be set to read-only and health care organizations will not be able to
modify the respective rows.

Currently, for ACPC only, eCQM data can be manually entered into CMIP.

For all other certification program purposes, chart-abstracted data must be reported on the standardized chart-abstracted measures and entered into the CMIP application via Joint Commission Connect® site.

Any of the Perinatal Care required measures can be submitted as either the chart-abstracted (CAM) or eCQM version of the measure to meet ACPC performance measure requirements.

PC-01 or ePC-01               Elective Delivery

PC-02 or ePC-02               Cesarean Birth

PC-05 or ePC-05               Exclusive Human Milk Feeding

PC-06 or ePC-06               Unexpected Complications in Term Newborns

PC-02 and PC-06 (severe rate only) have threshold requirements that must be met for ACPC (see certification manual for details). Organizations should take this into consideration when deciding which measure version to submit. It is important for organizations to have a process in place to ensure the eCQM data is accurate and valid. Some organizations choose to collect both the chart-abstracted version and the eCQM version to compare results.

Yes, organizations can submit all chart-abstracted (CAM) PC measures, all eCQM PC measures or a combination of both. Organizations must submit the same version of the measure for the entire year.

Data is required to be submitted quarterly into CMIP for both chart-abstracted (CAM) and eCQM measures for ACPC. Refer to the certification manual for details.

No, this functionality is not available. Organizations choosing to submit aggregate data from eCQM measures must enter the aggregate counts manually into CMIP.

Internal reports may be used to report monthly eCQM performance in CMIP. Data in CMIP are reported by month on a quarterly basis while eCQM data are reported to DDSP by quarter on an annual basis. Currently, the DDSP does not provide reports showing measure performance by month. Enhancements will be made to the DDSP eCQM reports to show monthly counts. Until such time, organizations can use internal data reports to report monthly eCQM performance; however, they should have a means of verifying accuracy of data being submitted. Remember, for ACPC, quarterly data submission is required.

In CMIP, choose either the chart-abstracted (CAM) or eCQM version from the drop-down menu for each measure. Complete the zero-attestation for the version NOT submitted. For example, if you select the CAM version of PC-01, you will need to check the zero-attestation box for the eCQM ePC-01 measure.

Open

Organizations must have a way to separate their data prior to submission. Data for ACPC must be from individual certified sites.

CAM and eCQM data will be reported separately. Once there are enough sites submitting data on each measure version, reports will include comparison data.

Due to how Tab 6 is populated in CMIP, all Perinatal Care measures are listed and need to be addressed. Measures for which the organization submitted data should be completed. Measures which have zero-attestation (no data submitted) will need to have NA entered into the fields.

For TJC only eCQMs: https://www.jointcommission.org/en/measurement/specification-manuals/electronic-clinical-quality-measures/

For CMS required eCQMS: https://ecqi.healthit.gov/

Please submit any measure questions to the Question Forum on our website at: https://manual.jointcommission.org .

Contact your Certification Account Executive if you have additional questions.

Additional information regarding certification is available on The Joint Commission Website:

https://www.jointcommission.org/what-we-offer/certification/certifications-by-setting/