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Measure Requirements: Chart and eCQM

3 JAN 2022 last update

Section 4: Measure Requirements: Chart and eCQM


4.1: Did all chart-abstracted measures go away in 2022?
No, chart-abstracted measures are not going away in 2022 for accreditation purposes. Effective CY2021, all hospitals are required to submit ORYX Performance Measurement (eCQM and/or chart-abstracted) data for accreditation. We are aligned with CMS and continue to evaluate measures.

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

4.2: Were ED 1, ED 2, or IMM-2 measures discontinued?
These measures remain optional for Joint Commission reporting purposes. Hospitals may elect to submit these measure, or Small/Critical Hospitals may submit these measures to meet their reporting requirements. Please refer to the full list of available measures available on our website, or copy and paste the following text into your web browser:

4.3: When will the data entry guide for 2022 DDSP submission be made available?
The 2022 DDSP Data Entry Guide will be available on our website March 2022:

4.4: Will we be able to upload chart abstracted data to the new DDSP instead of manually enter it?
Currently, there are no plans to provide upload capability of data for chart-abstracted measures.

4.5: Would you confirm a measure selected to be reported in 2022 must be reported for the entire year just as in past years?
For 2022, Chart-abstracted measures require the entire calendar year to be submitted (all 4 quarters) unless they are seasonal measures (e.g., IMM-2). eCQMs require three self-selected quarters of data; the quarters do not need to be consecutive.

4.6: Can an organization submit more than the required number of measures to Joint Commission?
Yes - Hospitals have the option of submitting any additional measures - chart-abstracted and/or eCQMs.

4.7: For chart-abstracted measures, what data will hospitals submit via the new DDSP?
The Joint Commission Guide for Data Entry of Chart-Abstracted Measures describes the aggregate data requirements for hospitals submitting chart-abstracted measure data. The information in the Guide is intended to assist health care organizations in their preparation for data entry of their aggregate data into the Joint Commission’s new Direct Data Submission Platform (DDSP).

The Joint Commission Guide for Data Entry of Chart-Abstracted Measures will be available on our website, or copy and paste the following web address in your internet browser:

4.8: If reporting the HBIPS, TOB, SUB, or IMM measures to The Joint Commission, who should be included in the patient population?
For Joint Commission reporting purposes, when determining the patient population to be included and sampled (using the Global Sampling specifications), all applicable inpatients from across the accredited hospital must be included regardless of location, setting of care, and/or payment source.

Hospitals submitting HBIPS, TOB, SUB and/or IMM measures must implement the Joint Commission’s sampling requirements. CMS accepts the Joint Commission’s sampling requirements for their Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program.

For additional information, see the Sampling section of the Specifications Manual for Joint Commission National Quality Measures

4.9: When are chart-abstracted measures due to The Joint Commission
Chart-abstracted data are due quarterly* (1Q due 6/30, 2Q due 9/30, 3Q due 12/31 and 4Q 03/31), reporting monthly, aggregate data points for each quarter via the new Direct Data Submission platform.

Important note: Due to the discontinuation of the Apervita DDSP and the implementation of the new Joint Commission DDSP, CY2021 and CY2022 data will be submitted during the second half of 2022.

4.10: How do organizations utilize the DDSP for submission of chart-abstracted measures?
HCOs collect and report monthly data points on chart-abstracted aggregate data (e.g., numerator, denominator, etc.) on a quarterly basis using the DDSP. No patient level data is submitted. HCOs submit numerator and denominator data by month, with a few additional data points including inpatient population (IPP) and exclusions (as needed by measure). Refer to the: Joint Commission Guide for Data Entry of Chart-Abstracted Measures

4.11: What if we cannot identify four eCQMs that are applicable based on our hospital services provided or patient populations?
As with the chart-abstracted measures, selections should be based on populations and services provided. If a hospital does not provide a service(s) addressed by certain eCQMs such that the hospital is unable to identify four applicable eCQMs, then the hospital would report on only those eCQMs for which it has the relevant patient population/service. Hospitals should not select eCQMs for which it has no patient population and would be reporting zero values.

Important note:
Effective CY2022, hospitals unable to meet the eCQM requirement and are granted an extenuating circumstance (see question 2.8 regarding ECRs) by The Joint Commission must substitute chart-abstracted measure(s) and submit those chart-abstracted measures for all four quarters of the calendar year.

4.12: Can you elaborate on HCOs that go above and beyond the minimum ORYX eCQM requirements, and how they can be eligible to be recognized as part of the Pioneers in Quality program.
Additional information will be provided in 2022 regarding eligibility for recognition. See our website for additional information:

4.13: Do you have to submit the same quarter of eCQM data to the Joint Commission as you do for CMS?
Joint Commission requires reporting for at least three self-selected quarters (Q) of 2022 data (Q1, Q2, Q3, or Q4). The same eCQMs must be submitted for all quarters. The Joint Commission and CMS do not share data and there is no requirement to submit the same measures/quarters to each entity. For eCQMs, the quarter(s) being submitted are at the discretion of the hospital. The same measure(s) must be submitted for a minimum of three quarters, but the selected quarters may vary.

4.14: How soon can eCQM data be submitted?
QRDA I documents for CY2022 eCQM data may be submitted as soon as The Joint Commission has onboarded your hospital to the new DDSP and made the platform available. To submit data, the entire calendar quarter must be available.

4.15: May we submit eCQM data on a quarterly basis just like chart-abstracted data?
A minimum of three calendar quarters of data based on the hospital’s selection of four eCQMs are due at The Joint Commission no later than the annual deadline date. Hospitals may submit their eCQM data on a quarterly basis; however, the submission deadline is the same for all quarters of eCQM data submitted.