Open/close dates and deadlines are shown within the platform. We also provide a timeline document available in the ORYX FAQs and on the platform for additional information:

https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/71008257

Open/close dates and deadlines are shown within the platform. Please see the timeline document available in the ORYX FAQs for additional information:

ORYX Performance Measurement Timeline

https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/71008257

Reporting chart-abstracted performance measurement data is performed quarterly*:

• 1Q (Jan, Feb, Mar) data are due by June 30

• 2Q (Apr, May, Jun) data are due by September 30

• 3Q (Jul, Aug, Sep) data are due by December 31

• 4Q (Oct, Nov, Dec) data are due by March 31

*Refer to the measure requirements, as some measures are seasonal or all four quarters are submitted during the 4Q timeframe.

Chart-abstracted measures for accreditation purposes will be 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 no longer has contracts with ORYX vendors, organizations may use vendors / consultants to assist them in collecting and aggregating the patient data required by the measures at their discretion.

  • the Invite & Manage User functionality of the DDSP allows organizations to invite vendors / consultants to the DDSP specifically to assist them with their chart-based data submission.

Yes.

The Joint Commission Guide for Data Entry of Chart-Abstracted Measures describes the aggregate data requirements for organizations submitting chart-abstracted accreditation measure data and is intended to assist health care organizations in their preparation for data entry into the DDSP.

Yes.

The Specification Manuals still contain, among other items, information concerning the initial patient population, sampling requirements, measure information forms, measure algorithms, patient-level data elements, ICD and medication code tables.

The measures your organization is expected to submit is determined by your organization's ORYX requirements: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/403472385

All selections are managed within the DDS Platform.  Organizations no longer need to notify The Joint Commission in advance of measure selections. 

Chart-abstracted measures are selected based on ORYX requirements for your organization.  Data is collected for a minimum of a calendar year to ensure that performance on a given measure is monitored over time for trends/patterns. Organizations may not start/stop chart-abstracted data entry/submission mid-year, except in the case of unit closures as applicable to the measure.

HCOs aggregate and report monthly data points on chart-abstracted measures on a quarterly basis using the DDSP

No patient level data is submitted effective 1/1/2020 discharges.

Please Note:

• The DDSP does not require the use of a vendor, but an organization may engage the services of a vendor at their discretion.

• A facility is responsible for all activity and users within the DDSP.

• A facility is responsible for verifying their data is submitting accurately and in accordance with posted deadlines.

• This discussion assumes the new vendor’s staff has been invited to the DDSP. 

A facility changing vendors at the beginning of a month shouldn’t have to perform any extra work from the perspective of the DDSP.  The previous vendor would provide the data to be entered through the last month they are responsible for and the new vendor would pick-up with the next month. 

It would be up to the organization to decide who would enter the data from the previous vendor.  It could be the site staff, the previous vendor, or the new vendor if that vendor agreed.  The DDSP has no restrictions on who an organization invites to their workspace, so if they want, they could have both vendors with access at the same time to support the entry of data for the quarter.

A facility changing vendors in the middle of a month will have to co-ordinate with the vendors on how they will be able to combine their measure results so data aggregation can occur. The below discussion is assuming the cut-off is on a day boundary. 

• The data elements for the proportion measures can be summed from the aggregate data provided by both vendors and an Observed Rate would be calculated from that summed data. 

• The ratio measures require the data element “Number of Unique Patients within the Numerator” in addition to the data elements required by the proportion measures.  This data element must be aggregated from across the entire monthly population of patients that are in the Numerator.  Since HBIPS-2 and 3 are event measures, it is possible that a patient is in the Numerator multiple times during the month.  The previous vendor would have to supply sufficient information about the patients in the Numerator such that the new vendor could combine it with their information to aggregate the data element without double counting patients.

• The continuous variable measures require the Observed Value calculation for each patient in the population during the month so the monthly Observation and Standard Deviation aggregate data can be calculated.  This requires the previous vendor to supply that information in a format that could be combined with the new vendor’s information for the month such that the new vendor could calculate the monthly aggregate data.

If a facility is changing vendors in the middle of the month and is unable to co-ordinate with the vendors or they are unable to access the aggregate data for the full month’s of data the previous vendor was responsible for, they should contact HCOOryx@jointcommission.org to discuss their situation.

Perinatal Care Attestation (submitting eCQMs instead of chart-abstracted measures to meet the perinatal care requirement) occurs within the chart-abstracted data entry module. Refer to the Perinatal Care Attestation on the Direct Data Submission Platform page for more information.

If an organization is not required to or electing to submit optional chart-abstracted measures, and are submitting only eCQMs to meet their ORYX requirements, the chart-abstracted status on the home page of “Not Started” can be ignored since it does not apply to your organization.

Do not enter zero for measures you are not submitting data for. This includes the PC measure for those organizations that do not provide obstetrical services.

The number of hospitals submitting all zeros for measures they don’t have data for inflates the count of hospitals selecting the measure potentially skewing comparative metrics on feedback reports.

Event cases are not sampled; organizations must report the complete population size; therefore, sample size = population size

• The Population size is reported as the total number of days of ALL Patients in the facility

• Denominator is the same IPP number but in hours; therefore, IPP number is multiplied by 24 to change the days to hours and then reported in denominator field

• IPP and Denominator of each stratum must be the same between two measures (Restrained and Seclusion) since it’s the number of all patients’ days in the facility for both measures

  • E.g., HBIPS-2b IPP and Denominator = HBIPS-3b IPP and Denominator

• Numerator count for each stratum/measure is as defined by the HBIPS-2 and 3 Algorithm by Minutes, but in the CAM form is reported by Hour

Example:

To simplify the example, assume all patients are in the same facility during the month, are all non-Medicare, and are all stratum 3.  These are the only non-Medicare patients in the facility during the month and all events receive a Measure Category Assignment = “E” in the appropriate measure.

With the HBIPS-2 / HBIPS-3 example of data collected on restraint and seclusion for 3 patients:

• Patient #1 has 10 psychiatric inpatient days, zero leave days, and with one restraint event lasting for 10 minutes, with no seclusion events.

• Patient #2 has 15 psychiatric inpatient days, zero leave days, and had 2 restraint events, with 5 minutes in one episode, and 10 minutes in another episode, and no seclusion events.

• Patient #3 has 30 psychiatric inpatient days, 1 leave day, no restraint events, and 1 seclusion event, lasting for 60 minutes.

• Overall, these patients represent 55 psychiatric inpatient days, 1 leave day, 2 patients in restraints for a total of 25 minutes of restraint, and 1 patient in seclusion for 60 minutes.

Open

Initial Patient Population – Non-Medicare is the non-Medicare Census Data for the unit/facility for the month, transmitted as Days.  This is not determined by the number of non-Medicare patients that are processed through the initial patient population algorithm.  Instead, it is calculated as

= (Psychiatric Inpatient Days - Leave Days), transmitted as Days

Each patient has a value for Psychiatric Inpatient Days and Leave Days (refer to the HBIPS Spec manual for more information).  So, for this example:  Initial Patient Population – Non-Medicare = (10-0) + (15-0) + (30-1) + (5-0) + (10-0) + (20-1) = 88. 

This same value will be reported for both HBIPS-2a and HBIPS-3a Initial Patient Population.

Number of Denominator Cases is the same non-Medicare Census Data for the unit/facility for the month used to calculate the Initial Patient Population – Non-Medicare, except Number of Denominator Cases is transmitted as Hours.  

= (Psychiatric Inpatient Days - Leave Days), transmitted as Hours

 Each patient has a value for Psychiatric Inpatient Days and Leave Days (refer to the HBIPS Spec manual for more information).  So for this example: 

Number of Denominator Cases = (10-0) + (15-0) + (30-1) + (5-0) + (10-0) +(20-1)= 88 days * 24 hrs = 2,112 hours

The same value will be reported for both HBIPS-2a and HBIPS-3a Denominator Population

Number of Numerator Cases is calculated from patient data successfully processed through the measure algorithm.  It is the sum of the monthly minutes (converted to hours) related to the event for those patients’ cases with a Measure Category Assignment = ‘E’ for the measure.

Number of Numerator Cases for the restraint measure = 30 minutes, converted to hours = .5 hours

Number of Numerator Cases for the seclusion measure = 90 minutes, converted to hours = 1.5 hours

Number of Cases for Ratio is calculated from patient data successfully processed through the measure algorithm.  It is the count of the number of patients represented in the data element Number of Numerator Cases.  This is not the count of the number of events during the month, it is the number of patients that had an event during the month.  If no event occurred, then a zero (0) is transmitted.

 Number of Cases for Ratio for the restraint measure = 3 patients

Number of Cases for Ratio for the seclusion measure = 3 patients