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General ORYX Information Basics

3 JAN 2022 last update

Section 2: General ORYX Information Basics

 

2.1: Why do hospitals have to collect data on Performance Measures?
The Joint Commission’s ORYX initiative integrates performance measurement data into the accreditation process. ORYX measurement requirements support Joint Commission accredited organizations in their quality improvement efforts.

The Joint Commission is more than just an accrediting body. We are actively engaged in helping organizations improve their patient safety and quality of care. As it relates to Performance Improvement, these quality and safety efforts are demonstrated by documenting elements of patient encounters, for example: How long did it take for a patient with stroke symptoms to receive a head scan? How long did it take for a patient to arrive in the ED and be treated before being discharged or admitted?

Hospital’s document all aspects of the care provided by collecting data from those encounters.

Here’s an example:
Pete the Patient arrives in the Emergency Department. Staff document the amount of time (in minutes) it takes from the time the physician decides to admit Pete into the hospital from the Emergency Department, until Pete leaves the Emergency Department to go to the inpatient unit.

Staff document this information in the medical record for all encounters that fit that criteria.

In our example, the median time for this to occur for a sampling of Emergency Department patients like Pete is 225 minutes over the course of the first quarter of the year.

Measure example - ED-2: Admit Decision Time to ED Departure Time for Admitted Patients: Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care. Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment.

2.2: What does The Joint Commission do with that data?
Performance Measurement data is submitted to The Joint Commission by all organizations with performance measurement requirements. The data is analyzed by statisticians at The Joint Commission and feedback is provided to facilities via Accelerate PI Dashboards. Measures which meet the Joint Commission accountability criteria are published on Quality Check® (see question 3.1 for more information on Quality Check)).

For the hospital, this information shows trends in the care provided on measures over time, as well as how the organization is performing compared to others. By providing feedback, hospitals can identify opportunities to improve patient safety and quality of care.

For the Joint Commission, this information is used to generate national benchmarks and identify opportunities for improvement in clinical topic areas. In addition, this information is available to surveyors, so they may discuss Performance Improvement efforts your organization may enact as a result of seeing trends or spikes in patient quality of care and outcomes.

2.3: We are a newly accredited facility. When do we begin collecting data to submit to The Joint Commission?
As a condition of participation (APR.04.01.01) organizations collect performance measures to meet specified ORYX measure reporting requirements for accreditation. The Joint Commission’s ORYX initiative integrates performance measurement data into the accreditation process. ORYX measurement requirements support Joint Commission-accredited organizations in their quality improvement efforts.

Elements of performance:

  • The organization collects measures relevant to their patient population to meet its current ORYX requirements.
  • The organization discusses with the surveyor how the data are used to identify, prioritize, and monitor performance improvement activities.
  • The organization uses each individual measure to identify patterns, trends, or variations for improvement opportunities.
  • Based on Joint Commission statistical analysis, the organization continues to use a measure in performance improvement activities and determines if the data suggest an unstable pattern of performance or otherwise identify an opportunity for improvement.
  • The organization resolves data quality issues for reported performance measures.
    For the most recent 12-month calendar reporting period, the organization achieves and sustains an acceptable level of performance, as defined by Joint Commission statistical analysis, for each measure before it discontinues its use in performance improvement activities.
  • The organization ensures that organization-specific data for its performance measures are submitted to The Joint Commission, in accordance with timelines established by The Joint Commission.

Policy: Organizations begin collecting ORYX Performance Measurement data the first calendar quarter following the receipt of their accreditation decision letter:

If the letter is received between 10/1 and 12/31, begin collecting 1Q data effective 1/1 patient discharges
If the letter is received between 1/1 and 3/31, begin collecting 2Q data effective 4/1 patient discharges
If the letter is received between 4/1 and 6/30, begin collecting 3Q data effective 7/1 patient discharges
If the letter is received between 7/1 and 9/30, begin collecting 4Q data effective 10/1 patient discharges

Note: Organizations are encouraged to keep up to date on any changes in the ORYX requirements by reviewing recent issues of The Joint Commission Perspectives® or by going to the “Measurement” area on The Joint Commission website.

2.4: What is the difference between our Joint Commission HCO ID number and our CCN number?
The Health Care Organization Identification number (HCO ID #) is not the same as CMS’ CCN. The HCO ID # is a unique number assigned by The Joint Commission. The Joint Commission’s HCO ID # can most easily be found when logged into your organization’s Joint Commission Connect Extranet site, shown in the upper right-hand corner, under the facility name and address.

2.5: With the goal being burden reduction and alignment of The Joint Commission and CMS, is there any possibility that we will not have to submit measures for Joint Commission and CMS into two different platforms?
The Joint Commission and CMS are separate entities with separate program requirements. The data is used for different purposes. There are no systems or infrastructure in place to share data between the two organizations.

2.6: Are the TJC changes aligned with CMS changes?
The Joint Commission is aligned with CMS on the requirements of reporting 3 self-selected quarters of eCQM data for each of four self-selected eCQMs for CY2022. CMS has 9 eCQMs available for selection and The Joint Commission has 13 eCQMs available for selection. The Joint Commission offers the following additional eCQMs for selection: ePC-01, ePC-02, ePC-06, and new for CY2022 – eCQM only ePC-07. For CY 2022, CMS and The Joint Commission both utilize the chart-abstracted measure PC-01.

Note:
The Joint Commission aligns with CMS requirements as closely as possible, however there are times when goals or program needs differ between the two entities and this necessitates variation.

2.7: If an Acute Care Hospital is receiving an eCQM hardship exemption from CMS for calendar year 2022 would we also receive a hardship exemption from TJC?
The Joint Commission and CMS are separate entities. If you are not able to submit all/part of your measure requirements to The Joint Commission, you must also request an exception from TJC. Send an email to to request an Extenuating Circumstance Request (ECR) form. (Refer to question 2.8 regarding timeline of ECR requests)

2.8: Does the Joint Commission have any type of extraordinary circumstances or exemption process for hospitals?
Hospitals who believe they have an extenuating circumstance that would impact CY2022 eCQM and/or chart-abstracted data for accreditation purposes should request an Extenuating Circumstance Request (ECR) form via email to:

Important note:
Hospitals required but unable to submit eCQMs must request and be granted an exception prior to the deadline to submit 1Q2022 chart-abstracted data, as any organization unable to meet their eCQM requirement must submit three (3) chart-abstracted measures for all four (4) quarters of CY2022.

If a hospital believes they are unable to submit chart-abstracted measures for any reason, they should submit a request for extenuating circumstances thirty (30) days prior to the quarter close of the affected quarter(s).

2.9: We would still be required to abstract PC-01 for CMS even if we submit 3 quarters of all the PC measures in eCQM format, correct? Can we still submit the exact same QRDA I file to the DDSP as we do to CMS?
Chart-abstracted PC-01 is required to be reported for the CMS Hospital Inpatient Quality Reporting Program (HIQR). For The Joint Commission only, any or all of the required chart-abstracted Perinatal Care Measures (PC-01, PC-02, PC-05 and PC-06) may be submitted or HCOs may instead submit a minimum of three quarters of eCQM data (ePC-01, ePC-02, ePC-05 and ePC-06*) instead of four quarters of the corresponding chart-abstracted measures.

*The new ePC-07 measure is optional and is not required.

2.10: Why don’t I get ORYX email notifications and how can I be added to the list to receive these communications?

There are a few possible reasons why you may not receive ORYX email notifications:

  1. ORYX email notifications are sent to the individuals documented within your hospitals Joint Commission Connect site. Notifications are primarily sent to the listed ORYX Contact, with additional notifications going to the Primary Accreditation Contact.
    Note: If you are not listed as either the ORYX Contact or the Primary Accreditation Contact for your hospital, please contact your hospital’s Joint Commission Connect Site Administrator, as they are the only one with the authority to modify or add to your hospital’s list of contacts.

  2. If you are a listed contact (i.e., ORYX or Primary Accreditation Contact), check to see if you have opted out of receiving emails from The Joint Commission. You may have opted out in one of two ways, either by checking the opt-out box on the “Security Admin” page on Joint Commission Connect and/or you have clicked the ‘One Click Unsubscribe’ link at the bottom of an email sent by The Joint Commission. Users that have opted out of receiving e-mails and want to opt back in, need to contact for assistance.

  3. If you have not opted out of receiving emails, please check with your internal IT department and ask if your hospital is using email filtering. Hospitals using email filtering need to whitelist (see definition below) specific domains and email addresses to ensure all communications are received.

    For general Joint Commission communication, whitelist The Joint Commission Domain: (@jointcommission.org)

    Definition: A whitelist is a list of e-mail addresses or domain names from which an e-mail blocking program will allow messages to be received. E-mail blocking programs, also called spam filters, are intended to prevent most unsolicited e-mail messages (spam) from appearing in subscriber inboxes. Depending on your email software, emails may also go to a clutter/junk/spam/other folder.  If you are uncertain how your hospital handles whitelisting, please contact your internal information technology/systems staff.

2.11: Where do I ask questions regarding various measurement topics such as ORYX requirements, data submission, etc.?
ORYX and Performance Measurement: For questions related to ORYX measure requirements, extenuating circumstance requests, and related processes, send an email to: ; be certain to include your HCO ID # in the subject line.

Chart-Abstracted Specifications: Measure questions related to Joint Commission Specifications must be submitted to the Wiki Platform: https://manual.jointcommission.org/

Joint Commission supported eCQMs: eCQM questions related to Joint Commission supported eCQMs must be submitted to the Wiki Platform: https://manual.jointcommission.org/

eCQM Specifications: Measure questions related to eCQM specifications should be submitted by accessing support resources available on the Joint Commission website, or copy and paste the following web address in your internet browser: https://www.jointcommission.org/measurement/specification-manuals/electronic-clinical-quality-measures/

Direct Data Submission Platform (DDSP): Once the new DDSP is launched, additional communications may be provided regarding any new processes related to questions / support.

2.12: How are hospitals billed for the ORYX annual fee?
HCOs with ORYX requirements are directly billed an annual fee in January based upon organizational weighted volumes for both eCQMs and chart-abstracted submissions. The ORYX annual fees are billed as a separate invoice to allow flexibility to organizations internal payment processes. Staff with access to their Joint Commission Connect site may view their invoice: Survey Process > Contracts and Billing > Fee, Billing and Invoice Information

2.13: Is there a separate fee for data submission?
There are no separate fees for use of the data submission platform.

2.14: Why did TJC move the submission deadlines for 2022?
On Sept. 19, 2021, Apervita notified us that they would cease all business at the close of Sept. 30, 2021. As a result of their business decision, the Apervita platform for direct data submission of chart-abstracted measures and/or eCQMs shut down permanently, resulting in the inability for hospitals to submit ORYX performance measurement data to The Joint Commission. Due to this, chart-abstracted and eCQM accreditation data submission timelines for 2021 and 2022 data will be delayed. A new Joint Commission Direct Data Submission Platform (DDSP) is being built to collect both chart-abstracted and eCQM data. Hospitals must continue to collect, aggregate and trend their ORYX measurement data for performance improvement and accreditation survey activities. We anticipate that hospitals will submit their 2021 and 2022 data to the new DDSP in the second half of 2022. A more specific timeline will be communicated when the platform launch date has been determined.

An infographic on deadlines and target dates will be posted on our website under, "Supporting Materials" when it is available: Website

2.15: When are CY2022 eCQM data due to The Joint Commission
For CY2022 eCQM data, the annual submission deadline is March 15, 2023. eCQMs may be submitted anytime between when the CY2022 data submission period opens (expected in the second half of CY2022) up until the deadline (usually March 15th of the following year). As a reminder, eCQMs are currently submitted retrospectively, e.g., CY2022 eCQMs are due no later than March 15, 2023, and CY2023 eCQMs are due no later than March 15, 2024.