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General ORYX Information Feedback and Public Reporting

3 JAN 2022 last update

Section 3: General ORYX Information Feedback and Public Reporting

 

3.1: What is Quality Check?
The purpose of Quality Check is to list Joint Commission accreditation status, and provides information about accredited organizations, including National Quality Improvement goals for performance measures.

Hospitals can use the DDSP to start reporting this measure to better understand the measure construction and calculation.

3.2: What ORYX data will be publicly reported on Quality Check?
Hospitals reporting chart-abstracted measures continue to have their data and performance on the chart-abstracted measures reported on Quality Check.

3.3: What data will be reported and displayed in the ORYX Performance Measure Report provided quarterly to the hospital?
The Joint Commission has transitioned from the ORYX Performance Measure Report (PMR) to the Accelerate PI™ Dashboard. The dashboard is available via the hospital's Joint Commission Connect site, under “Resources and Tools”. The Accelerate PI Dashboard includes both chart-abstracted and/or eCQM data submitted.

Accelerate PI is the only method of data visualization for ORYX data starting with CY2019 data. The Joint Commission provided the PMR data reported through 4Q CY2019. Going forward, all ORYX data visualizations are in the Accelerate PI format. Prior PMRs are available for organizations to download from their JC Connect® sites through June 2022, at which point the PMRs will be removed.

3.4: When will eCQM data be publicly reported?
At this time, eCQM data is not being publicly reported on Quality Check by The Joint Commission. The Joint Commission continues to evaluate the data received and will determine public reporting when a majority of the HCOs participate in eCQM submission and enough data is available to be reliable.

3.5: Will hospitals reporting eCQM data receive reports like the Joint Commission’s current chart-abstracted ORYX Performance Measure Reports?

  • eCQM data for CY2019 reporting periods and forward are available to the HCOs via the Accelerate PI Dashboards.
  • Chart-abstracted data for CY2020 reporting periods and forward are also available to the HCOs via the Accelerate PI Dashboards.
  • Accelerate PI Dashboards are accessible via an organization's Joint Commission Connect site.
  • Please note: due to the delayed reporting of CY2021 and CY2022 data, reports will be delayed as well.

3.6: When will we see 2020 data on Quality Check?
Chart-abstracted measure data is now posted on Quality Check for January 2020 - December 2020 with the following notation: The Joint Commission recognizes accreditation quality measure data collection and reporting for 2020 may not be reflective of an organization's true level of performance given the National Pandemic. In addition, The Joint Commission sought to reduce burden on organizations by making data submission optional for 1Q 2020 and 2Q 2020. Those organizations that opted not to submit all 4 quarters of 2020 data will not have their 12-month data displayed on Quality Check.

3.7: How do we get access to the eCQM State and National Comparisons all eCQMs?
We do not publish national or state eCQM rates. HCOs can access State and National rates for the eCQMs submitted on the Accelerate PI Dashboard, within Joint Commission Connect.

3.8: If we choose to submit PC measures electronically for 2022 and only submit 3 quarters, how will this data be publicly shared?
The Joint Commission continues to evaluate the eCQM data received and will begin public reporting when there are enough HCOs participating to provide feedback.

3.9: Where can I find the PC measures (chart-abstracted) benchmarks?
Chart-abstracted measure data is now posted on Quality Check for January 2020 - December 2020 with the following notation:

The Joint Commission recognizes accreditation quality measure data collection and reporting for 2020 may not be reflective of an organization's true level of performance given the National Pandemic. In addition, The Joint Commission sought to reduce burden on organizations by making data submission optional for 1Q 2020 and 2Q 2020. Those organizations that opted not to submit all 4 quarters of 2020 data will not have their 12-month data displayed on Quality Check.

3.10: Will the DASH information be used for thresholds for the safe use of Opioid measures?
The Joint Commission will provide benchmarking information on the Accelerate PI Dashboard for the upcoming opioid measure once reporting begins and there are enough organizations that submit the data on the measure (to meet our parameters for publishing a benchmark).

3.11: How do I request access to Accelerate PI? It's a 'grayed-out' option.
Please contact the individual in your hospital that is an Administrator for JC Connect. Only they can provide you access to the Accelerate PI Dashboard.

3.12: Is it possible to get more current data on Accelerated PI dashboard?
The Joint Commission understands the importance providing timely data to organizations. The HAP-Other reports contain measures selected from the CMS Compare dataset. For this reason, the data in the Accelerate PI dashboards can only be as recent as the data posted on CMS Compare. They are updated at least biannually with the most recent data available from CMS Compare. The HAP-ORYX reports contain ORYX measure data. These reports are updated quarterly with the most recent data submitted to The Joint Commission.

Please note:
Due to the delayed reporting of CY2021 and CY2022 data, reports will be delayed as well.