Joint Commission
Extenuating Circumstances
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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
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 CY2025, all forms must be received at The Joint Commission no later than 30 days prior to the 1Q chart-abstracted deadline (June 1, 2025). 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.
*APPLICABLE TO CY2025: Large acute care hospitals with obstetrical services and requesting an ECR for eCQMs only:
Perinatal care measures are required; organizations with obstetrical services must submit chart-abstracted PC-02, PC-06, plus one additional chart-abstracted measure applicable to their patient population / services offered.
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 Information
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. Provide requested information in all relevant fields within 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 declined and required to be resubmitted.
Please note in the instance of multiple facilities affected within an organization system, one form must be submitted by each affected facility.
Submit the completed form via the DDSP “HCO Characteristics> Extenuating Circumstances” tab (more information on how to use the DDSP form is provided below).
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.
Important Note: Eligible Organizations, Hospitals, and Critical Access Hospitals (CAHs) must submit a new application for any subsequent years. Organizations requesting an ECR for five or more consecutive years must provide additional supporting documentation, which may include requests/ approvals from CMS for exceptions, documentation/letter from an EHR vendor related to timeline delays, and/or any other documentation if pertinent.
Where to access the ECR form:
To submit an extenuating circumstance request, log in to the DDSP and navigate to “HCO Characteristics” via the left hand side menu. Within HCO Characteristics, select the “Extenuating Circumstances” tab.
Complete all applicable and/or required fields. Information on specific fields are available by hovering over the “i” icon.
Once all applicable fields and information is complete, scroll to the bottom of the page to submit the ECR for review.
When the form is submitted, you can view the status under the ECR tab. We will follow via email from HCOORYX@jointcommission.org to confirm receipt, request additional information, and provide an attached decision letter for your records. The status of the ECR will also be updated within the DDSP ECR tab.
If the request is still pending, an organization use the “Link to Detail Form” to make changes or withdraw the ECR if needed.
If the form is modified, be certain to scroll to the bottom of the page and submit the form for review.
If your organization has any difficulty or questions using the form, please submit a platform support ticket via the “Need Help?” link.
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