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Topics Covered in this section:

• What are Extenuating Circumstances?

• Organizations required but unable to submit eCQMs

• Organizations required but unable to submit chart-abstracted data

• Extenuating Circumstance Request form

What are Extenuating Circumstances?

Organizations may experience a variety of mitigating situations beyond their control that will impact the ability to report ORYX performance measure data to The Joint Commission for a defined period of time.

Examples such as: EHR transition, natural disasters such as hurricanes, etc.

Organizations requesting a modification in The Joint Commission’s ORYX Performance measure reporting requirements should carefully read the information below before completing the Joint Commission Extenuating Circumstances Request (ECR) Form included at the bottom of this page.   

Organizations required but unable to submit eCQMs:

To be considered for an exemption from submitting eCQM data for the current calendar year requirements, all forms must be received at The Joint Commission no later than 30 days prior to the 1Q chart-abstracted deadline. If no eCQMs will be submitted, organizations are required to submit a minimum of three (3) chart-abstracted measures for the entire calendar year*, unless the request is for an exception for submission of any data. Organizations were notified of this change to ECRs per the requirements documents provided to facilities October 2021. 

Organizations required but unable to submit Chart-abstracted measures:

To be considered for an exemption from submitting chart-abstracted data for the current calendar year requirements, all forms must be received at The Joint Commission no later than thirty (30) days prior to quarter close applicable to the request.

Form

Individual organizations or healthcare systems requesting consideration for multiple facilities within their system need to provide as much information as possible regarding the situation leading to the request. Include supporting documentation if applicable. Please check or enter the requested information into all relevant fields on the form.  Be certain to provide a brief, high-level description of the situation impacting the organization’s ability to report ORYX measure data to The Joint Commission. Incomplete / inaccurate forms will be returned and required to be resubmitted.

Please note the form may be used by either an:

• Organization for use by an individual facility, or

• Healthcare System for use by healthcare systems seeing consideration for multiple of its member facilities

Return the completed form via email to HCOORYX@jointcommission.org and include your HCO ID# or Healthcare System Name in the subject line and “Request for Extenuating Circumstances” as appropriate.  

Response from The Joint Commission

Forms are reviewed as they are received and may require additional information.  Each request is considered on its own merits and a decision whether to accept the request rendered accordingly.

Download the ECR form to your Desktop:

To access the form, click on the file preview below, then click the cloud download icon. If you are unable to download the form or are restricted by your IT security requirements, email hcooryx@jointcommission.org and request the ECR form be sent to you via reply email. ECR forms are completed then sent via email to hcooryx@jointcommission.org for review.

Downloadable Microsoft form:

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