Short Demo for Chart-Abstracted Data Entry, Submission, and Status (duration: 13:55 minutes)
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Table of Contents:
Purpose
Accessing the data entry tool
Chart-Abstracted Measure Submission’ data entry tool
Switch HCO or measure
Select a quarter
View and Edit data
Error Messages
Zero attestation of the Initial Population or Denominator
View Submission Status
Purpose
When selecting ‘Chart-Abstracted Measure Submission' from the menu, the ‘Chart-Abstracted Measure Submission’ page becomes available displaying the list of chart-abstracted measures. Access to the 'Chart-Abstracted Measure Submission’ data entry tool for each measure is available from this page.
The Chart-Abstracted Measure Submission data entry tool is for entering aggregate Chart-Abstracted data. This page describes how to:
determine if you have permission to enter data in the tool
navigate within the tool, switch between HCOs, measures, quarters
check data submission
Reference Material
The Joint Commission Guide for Data Entry of Chart-Abstracted Measures defines the aggregate chart-abstracted accreditation measure data to be entered into the DDSP data entry tool. It is available within these help topics (quick link: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/112001025), with an external link also posted on The Joint Commission Website.
The Specification Manuals contain the measure algorithm flows and data element definitions and describe the chart-abstracted measures and data. . These aid in understanding the measures and the data that is aggregated and then entered into the Chart-Abstracted Measure module on the DDSP.
Within the data entry tool, information icons provide information about each data field. When users hover the cursor over the information icon, it provides information such as the definition of the data that has been abstracted and aggregated.
Aggregate Data Entry
HCOs aggregate and report monthly data points on chart-abstracted measures on a quarterly basis using the DDS Platform. Effective CY2020, no patient level data is submitted.
It is expected that organizations will ensure the accuracy and completeness of their patient-level data they’ve processed through each measure’s algorithm and will validate that the derived aggregated data represents the care actually provided.
The DDSP will validate the entered aggregate data by performing consistency and edit checks to assure the integrity of the submitted aggregate data.
Hospitals can attest to submitting ePC measures (eCQMs) instead of chart-abstracted Perinatal Care (PC) measures via the Chart-Abstracted Submission menu.
The Perinatal Care Attestation topic provides additional information.
How to Use
Accessing the data entry tool
The Measure Selection list shows the measures. For each measure, the list shows whether it is required or not available for data entry, shows each measure’s completion status by quarter and an open button. In addition, the list shows which quarters are open for data entry and, for those open, what each quarter’s submission deadline (close date) is.
Open a measure by clicking the ‘Open’ button in the Measure List on the right. This opens the data entry tool for the selected measure.
Chart-Abstracted Measure Submission’ data entry tool
Data may be changed up until the close of the quarter.
Switch HCO
Users with access to multiple HCOs can Switch to another site from the top of the measure data entry screen via the “Switch HCO” dropdown list at the top middle of the page:
The HCO and a dropdown HCO selection list (to switch HCOs) is in the top middle section of the page.
If you do not have access to more than one HCO, you will not have a “Switch HCO” button.
Switch Measure
There are two ways to switch to a different measure from within the chart-abstracted measure submission page. In the upper right of the module, below the Need Help? button, select either ‘Return to Measure List’ or choose a different measure from the drop down list box next to it.
Select a quarter
If a measure is not available for certain quarters then no form will be available. An example of this is the seasonal measure IMM-2 which does not allow data for quarters 2 and 3.
Quarters are displayed in tabs above the data fields. When a new data submission period starts, the First Quarter tab is automatically selected. If a quarter is open, its status will be ‘Closes mm/dd/yyyy’. Data incorrectly entered or omitted may be resubmitted within a specific timeframe. If Resubmission is available, the tab will show ‘Resubmission Ends on mm/dd/yyyy’. Otherwise, it is ‘Closed’ or ‘Not Yet Open’. Click on the quarter tab to view or change its data.
Select a quarter by clicking one of the quarter tabs.
View and Edit data
In order for data to be entered and saved, at least one entire month of data must be entered.
The Edit/ Submit buttons and statuses in the upper right corner of the screen are summarized below. Different messages and buttons appear as data is entered, checked for errors, and then saved and submitted.
To add or change data, click on ‘Edit’.
Click on the toggle button 'Enable to submit data” for each month.
Enter data. Click ‘Submit’ to save. If no errors, ‘Edit’ appears and data is saved, else ‘Month – Errors’ (in red text) will show on the top of the month that had error .
Error found. Correct the errors click ‘Submit’ again. If data passes, ‘Edit’ reappears.
Note: In order for the platform to save entered data, all applicable fields for a month must be entered without errors. All three months of data must be entered and submitted by the data submission deadline for it to be considered “submitted” for the quarter.
Users may edit entered and saved numeric data anytime prior to the close of quarter. They may resubmit incorrectly entered/omitted data within the resubmission timeframe.
Error Messages
All fields must have values and pass validation before data is saved. Error messages appear under any fields that failed validation. If there are errors, the ‘Done’ button changes to ‘Error’.
If the Submit button does not switch back to view mode (Edit) after you click it, remember to scroll down to check all of the data for errors.
Each field has an i information icon that provide useful information when the cursor hovers over it. The information summarizes data definition and requirements. This helps to explain validation errors.
Zero attestation of the Initial Population or Denominator
Organizations should not enter zero for measures they are not submitting data for*.
In order to meet the intent of the ORYX requirements, organizations must select measures based on their patient population / services offered.
Refer to your organization’s Joint Commission Standards manual APR.04.01.01.
*With exception is the case of unit closures, such as an obstetrical unit, in which case zeros must be entered for the remainder of the calendar year.
If zero is entered for Initial Population, Denominator or Population, zero attestation is required before saving. A zero-attestation box appears and must be checked. After the box is checked, some data fields are deactivated.
Calculated values have a blue background with white text. Click ‘Done’ to check the entered data. If the entered data passes all of the rules, the remaining fields are calculated, and the data is saved..
View Submission Status
To view the status of data entry, login to the DDSP home page. Under the Chart-Abstracted Measure Submission Status section, you can click on the ‘Open’ button either from In Progress or Complete menu. You will get the list of HCOs and the ‘Download Submission Report’ button for each HCO you have access to. From there you can ‘Download Submission Report’ for the facility(s) you have permission for.
Continue to the next section: Chart-Abstracted Error Messages
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