The Joint Commission

General: Accreditation & Certification Data Submission Requirements

Accreditation

eCQMs

eCQMs for accreditation purposes will continue to be:

  • using CQL-based HQMF eCQM specifications:

    • ePC-02 is a Joint Commission only specification, available on our website

    • the remaining eCQMs available for accreditation purposes have been published by CMS on the eCQI Resource Center

  • submitted to The Joint Commission via the DDSP using:

    • HL7’s QRDA I Release 5.1 Implementation Guide (IG) and

    • CMS' 2020 QRDA I IG for Hospital Quality Reporting

    • note: ePC-02 will use the above two IGs, The Joint Commission will not be releasing a separate IG for this measure.

Chart-abstracted Measures

Effective CY2020, chart-abstracted measures for accreditation purposes are submitted:

  • as Aggregate Data (e.g., Initial Population, Sampling Frequency, Sample Size, Denominator, Numerator, Exclusions)

  • the data will be entered into data entry forms on the DDSP

  • while The Joint Commission will no longer have contracts with ORYX vendors, organizations may continue to use vendors / consultants to assist them in collecting and aggregating the patient data required by the measures

  • the Invite & Manage User functionality of the DDSP will remain the same, meaning that organizations may invite vendors / consultants onto the DDSP specifically to assist them with their chart-based data submission.

Certification

IMPORTANT NOTE: At this time, Certification data is not entered in the DDSP; certification data is provided within the Certification Measurement Information Process (CMIP) application within JC Connect. The following is provided as informational only.

eCQMs

At this time, there are no eCQMs available for use within any of the Certification programs

Chart-abstracted Measures

Effective CY2020, chart-abstracted measures for certification purposes are submitted via the CMIP tool:

  • as Aggregate Data (i.e., Denominator and Numerator)

  • the data will be entered into data entry forms within the Certification Measurement Information Process (CMIP) application within JC Connect

  • while The Joint Commission will no longer have contracts with ORYX vendors, organizations may continue to use vendors / consultants to assist them in collecting and aggregating the patient data required by the measures

  • if the staff that will be entering your certification data does not have access to JC Connect, your organization’s JC Connect Security Administrator must Create a New User and provide the individual ‘Full' Security Rights to the CMIP application.

PLEASE NOTE: Joint Commission Connect is a secure, password protected website intended only for Joint Commission accredited or certified organizations. This website not only provides access to the CMIP tool, but your organization's accreditation and certification applications; survey process and continuous compliance information; and official communications.

 

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