Included in this section:

• Data Submission Timeline

• ORYX Initiative

• Measure Selections

• eCQMs Data Completeness

• eCQM Zero Case Attestation and Case Threshold (five or fewer) Exemption

• eCQM Data Usage

• eCQM Joint Commission Alignment with CMS

Data Submission Timeline:

Please see theORYX Performance Measurement Timeline for a comprehensive timeline. The following is a short summary of data submission timelines only.

CY2024 Data

CY2024 Chart-Abstracted Measures (CAM)

• 1Q 2024 (Jan, Feb, Mar): DDSP opens February 1, 2024 and data must be entered by June 30, 2024

• 2Q 2024 (Apr, May, Jun): DDSP opens May 1, 2024 and data must be entered by September 30, 2024

• 3Q 2024 (Jul, Aug, Sep): DDSP opens August 1, 2024 and data must be entered by December 31, 2024

• 4Q 2024 (Oct, Nov, Dec): DDSP opens November 1, 2024 and data must be entered by March 31, 2025

CY2024 Electronic Clinical Quality Measures (eCQMs)

• CY2024: DDSP opens TBD, 2024, Transmission period to submit data opens January 1, 2025, and data must be submitted by March 17, 2025

ORYX Initiative

The Joint Commission’s ORYX® initiative integrates performance measurement data into the accreditation process. ORYX measurement requirements are intended to support Joint Commission-accredited organizations in their quality improvement efforts. Performance measures are essential to the credibility of any modern evaluation activity for health care organizations.

The Joint Commission is pleased that the Direct Data Submission Platform (DDSP) enables an ORYX eCQM process that simplifies operations and reduces the burden for our accredited organizations while ensuring regulatory compliance and security.  The ability to receive performance measurement data directly from our accredited HCOs has been an important goal for several years.  This is based on feedback and ongoing work with our accredited organizations, as well as The Joint Commission’s commitment to advancing healthcare quality and patient safety through innovative, practical systems for healthcare data measurement that guide quality improvement.

As you participate in the DDSP, the below information is important for understanding the Joint Commission’s ORYX requirements and our eCQM alignment with CMS.

• ORYX Performance Measure Reporting Requirements

• What You Need to Know – ORYX FAQs

Measure Selections

All chart-abstraction measure and eCQM selections for accreditation purposes are managed within the DDS Platform. Organizations no longer need to notify The Joint Commission in advance of measure selections. Measures are selected based on ORYX requirements for your organization.

eCQMs Data Completeness

There is no acceptable number or percentage of QRDA I document rejections that must be met in order to submit data directly to The Joint Commission.  We encourage organizations to submit all their eCQM data, even if they believe it will be rejected.  This will facilitate learning about the DDSP’s Data Accuracy and Quality Improvement tools in researching and correcting QRDA I issues and the Joint Commission’s learning about the types of issues still occurring in the field as it relates to eCQMs.

• Data Upload:  Upload all QRDA I documents even if you know they will receive error messages and be rejected.   The Joint Commission provides suggestions and make requests to provide global improvements in the issues related with QRDA I document generation through various channels.  These channels include our routine discussions with CMS concerning data receipt issues and our HL7 membership and participation in the Clinical Quality Information (CQI) and Clinical Decision Support (CDS) HL7 workgroups.  These two workgroups are responsible for the maintenance of the Clinical Quality Language (CQL), Health Quality Measure Format (HQMF) and Quality Reporting Data Architecture (QRDA) I (patient-level data) standards which are used to create and submit eCQM data. 

CMS published eCQM Specifications

As an eCQM measure developer, The Joint Commission answers questions concerning eCQM specifications and associated value set members published by CMS via the Electronic Clinical Quality Measure (eCQM) ONC Issue Tracker. The electronic clinical quality measure (eCQM) Issue Tracker provides a public place for the eCQM community to submit questions and issues related to eCQM specifications.

Joint Commission only eCQM Specifications

The Joint Commission continues its commitment to actively developing and testing additional eCQMs. See the reporting year specifications and additional information regarding eCQMs that have been developed by The Joint Commission or will be maintained by The Joint Commission following removal by CMS. The Joint Commission uses the same data capture and submission standards for these eCQMS as those used by the aligned eCQMs.

Data Submission: 

• Errors messages, if possible, must be corrected as they result in the patient’s QRDA I document being rejected and the patient data cannot be submitted to The Joint Commission. 

• It is encouraged that Warning messages are reviewed and addressed when possible, as they may point towards potential incorrect eCQM evaluations.  However, patient’s QRDA I documents with only Warning messages may still be submitted to The Joint Commission.

eCQM Zero Case Attestation and Case Threshold (five or fewer) Exemption

The Joint Commission is aligned with CMS with allowing attestation for zero denominators in a measure or, if desired, invoking the case threshold exemption (five or fewer cases in the denominator).  Zero Case attestation and/or invoking the exemption will occur at time of submission.  

eCQM Data Usage

• Survey Process: eCQM data is not being utilized by surveyors in the accreditation process; however, organizations with successful eCQM implementation(s) are encouraged to share their experiences during their on-site survey.

• Public Reporting: The Joint Commission will not publicly report eCQM data on Quality Check.  

• ORYX eCQM Feedback Reports: The Joint Commission will provide hospital-specific eCQM Reports to all organizations that submit eCQM data. The reports will be available on the Joint Commission Connect Site for the respective eCQM reporting year.  If you do not have access to the Joint Commission Connect Site, please request a copy of the report from your ORYX Contact.

eCQM Joint Commission Alignment with CMS

For Inpatient eCQMs used by both The Joint Commission and The Centers for Medicare & Medicaid Services (CMS): The Joint Commission aligns with CMS on the eCQM version for each annual reporting period and associated data capture and submission standards.  Refer to the Joint Commission eCQM Version Alignment with CMS documentation for additional information, the specific standards, and Certified EHR Technology (CEHRT) requirements.

For Inpatient eCQMs used only by The Joint Commission: The Joint Commission continues its commitment to actively developing and testing additional eCQMs. See the Joint Commission eCQM Version Alignment with CMS documentation and reporting year specifications and additional information regarding eCQMs for more information.