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What is New

3 JAN 2022 last update

Section 1: What is New

 

1.1: What changes have been implemented regarding ORYX requirements / Accreditation data submission for CY2022?

  • Starting with CY2022, hospitals required or electing to submit eCQMs must submit a minimum of three (3) quarters of data to The Joint Commission. This is a change / increase from CY2021 reporting of two (2) quarters.
  • Hospitals who are required but unable to submit eCQMs and have been granted an extenuating circumstance from The Joint Commission, will be required to instead submit a minimum of three chart-abstracted measures for the full CY2022 calendar year.
  • In no case may an eligible Hospital or Critical Access Hospital be granted an extenuating circumstance exception for more than five consecutive years.
  • The “ePC-07 Severe Obstetric Complications” measure was added as a new Joint Commission only eCQM (specifications available by January 2022). There is no corresponding chart abstracted PC-07 measure. This measure is not required for 2022 collection but is offered as an optional measure to meet ORYX eCQM requirements.
  • Due to the discontinuation of the DDSP hosted by Apervita as a result of that company’s closure, CY2021 and CY2022 ORYX performance measurement deadlines will be delayed; a new Joint Commission DDSP will be available in the second half of CY2022, and hospitals will be able to submit required data at that time.

1.2: What are the 2022 ORYX Performance Measurement Reporting Requirements?
As a reminder, effective CY2021, for the Hospital Accreditation Program (HAP) and Critical Access Hospital Accreditation Program (CAH), ORYX Performance Measurement Reporting requirements include the following:

ORYX eCQM and/or Chart-Abstracted data submission:

  • Acute Care Hospitals are defined as having Licensed Beds >= 26 OR Outpatient Visits >= 50,000, and are no longer defined by ADC >10
  • Freestanding Psychiatric Facility reporting requirements are not defined by Licensed Beds / Outpatient Visits and are required to submit chart-abstracted HBIPS measures
  • Small Hospitals are defined as having Licensed Beds <26 AND Outpatient Visits < 50,000, and no are longer defined by ADC <= 10; Small Hospitals cannot self-report. (Refer to question 3.12 in “Measure Requirements” regarding self-reporting)
  • Critical Access Hospital (CAH) Accreditation Program reporting requirements are not defined by Licensed Beds / Outpatient Visits and are required to submit chart-abstracted measures and/or eCQMs; CAHs cannot self-report. (Refer to question 5.1 in “Measure Requirements”)
  • The Specialty Hospital designation was removed effective CY2021; all hospitals previously designated as "Specialty" for ORYX reporting purposes were placed in the appropriate ORYX policy based upon Licensed Beds and/or Outpatient Visits. (Refer to question 1.6 regarding self-reporting)

The CY2022 reporting requirements and list of available measures are available on our website or copy and paste the following web address in your internet browser: https://preview.jointcommission.org/-/media/tjc/documents/measurement/oryx/2022-oryx-reporting-requirements--october-19-2021.pdf

The Joint Commission Guide for Data Entry of Chart-Abstracted Measures which describes the aggregate data requirements for hospitals submitting chart-abstracted measure data is available on our website, or copy and paste the following web address in your internet browser: https://www.jointcommission.org/measurement/specification-manuals/chart-abstracted-measures/

1.3: Have any measures been retired or added for 2022 ORYX reporting requirements?
Retired: Neither the Joint Commission nor CMS has retired or removed any chart-abstracted or eCQM measures for CY2022.

Added:
The “ePC-07 Severe Obstetric Complications” measure was added as a new Joint Commission only eCQM (specifications available by January 2022). There is no corresponding chart abstracted PC-07 measure. This measure is not required for 2022 collection but is offered as an optional measure to meet ORYX eCQM requirements.

The CY2022 reporting requirements and list of available measures are available on our website or copy and paste the following web address in your internet browser: https://preview.jointcommission.org/-/media/tjc/documents/measurement/oryx/2022-oryx-reporting-requirements--october-19-2021.pdf

1.4: What measures are available for reporting in CY2022?
The CY2022 reporting requirements and list of available measures are available on our website or copy and paste the following web address in your internet browser: https://preview.jointcommission.org/-/media/tjc/documents/measurement/oryx/2022-oryx-reporting-requirements--october-19-2021.pdf

1.5: What is included in "outpatient visits"?
Per the description in your Joint Commission Connect eApp/General Application under Hospital site information > “Volume”, outpatient visits include: Includes all clinics, outpatient surgery, physical therapy, radiology. Excludes all Laboratory tests.

1.6: Can we self-report our data/make the data available at the time of survey?
Effective 1/1/2021 patient discharges, we removed the option of self-reporting data. All hospitals must submit eCQM and/or chart-abstracted data to The Joint Commission via the direct data submission platform (DDSP), which will be implemented in the second half of CY2022. Hospitals that self-reported in the past are required to submit their data via the DDSP.

1.7: Will the new Joint Commission DDSP platform be built out and ready for submissions by 3/15/2022 - the CY2021 eCQM submission deadline?
No – the new DDS platform will not be available by 3/15/2022. We anticipate that hospitals will submit their remaining CY2021 and CY2022 data to the new DDSP which will be available in the second half of 2022.

1.8: Do we need to resubmit 1Q2021 and 2Q2021 chart-abstracted data?
We do not anticipate hospitals will need to resubmit 1Q data, as that data was received. We are currently determining if the chart-abstracted data we received for 2Q2021 is complete, as the data submission deadline was the last day Apervita was in business.

1.9: Should we not be doing chart abstractions for the 3rd quarter at this time due to the platform not being available?
You should continue to abstract 3Q2021 and 4Q2021 data as the data will be required. ORYX performance measurement requirements have not been suspended. Organizations should continue ORYX performance measurement efforts and be prepared to provide data at the time of survey. We anticipate that hospitals will submit their 2021 and 2022 data to the new DDSP which will be available in the second half 2022.

1.10: With the retirement of Apervita platform we would like to understand our reporting requirements for CY2021.
The ORYX requirements remain the same, only the data submission is delayed. 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 which will be available in the second half 2022.