what you need to know about joint commission 2020 oryx ... · ⎻epc-01 elective delivery (retained...

What you need to know about Joint Commission 2020

ORYX® Performance Measurement Requirements

Tricia Elliott, MBA, CPHQ

Director, Quality Measurement

October 8, 2019

2

© 2018, The Joint Commission

Topics for today:

• 2020 ORYX Requirements

• Direct Data Submission

• ORYX Performance Measurement Billing

• Certification Standardized Measures

• Resources

3


2020 ORYX Requirements

4


⎻ The Joint Commission has announced its 2020 ORYX® reporting requirements.

⎻ During 2019, all hospitals transitioned to the Direct Data Submission Platform (DDSP) for submission of electronic clinical quality measure (eCQM) data directly to The Joint Commission.

⎻ In 2020, hospitals will use the DDSP for submission of chart-abstracted measures — meaning in 2020, organizations have one place to submit both eCQM and chart-abstracted data.

2020 ORYX® Performance Measure Reporting Requirements

5



https://www.jointcommission.org/assets/1/18/2020_ORYX_Reporting_Requirements_9_11_2019.pdf

https://www.jointcommission.org/assets/1/18/2020_ORYX_Reporting_Requirements_9_11_2019.pdf

6


2020 ORYX® Performance Measurement Requirements

• eCQM reporting requirements for Hospital Accreditation Program with an ADC > 10

• Acute care hospitals with an ADC >10 report a minimum of four self-selected eCQMs applicable to the services provided and patient populations served by the hospital, for a minimum of one self-selected quarter.

• 10 eCQMs are available for selection (eED-2, ePC-01, ePC-02, ePC-05, eSTK-2, eSTK-3, eSTK-5, eSTK-6, eVTE-1, eVTE-2).

• All hospitals utilize the DDSP for eCQM data submission.

7



• Chart-abstracted measure reporting requirements for acute care Hospital Accreditation Program with an ADC > 10

• Acute care hospitals with an ADC > 10 that provide obstetrical services report one required chart-abstracted measure, which is PC-01.

• In addition, hospitals with at least 300 live births also are required to report on all chart-abstracted perinatal care measures: PC-02, PC-05 and PC-06.

• Please note: Effective Jan. 1, 2020, PC-03 and PC-04 have been retired from the Perinatal Care measures.

NOTE: Hospitals can expect additional communication and instruction from The Joint Commission in early 2020 regarding the transition to the DDS Platform.

8


Changes to chart-abstracted submission requirements

• Starting with calendar year 2020 for Hospital Accreditation Program

• The Joint Commission no longer has contracts with ORYX chart-based vendors.

• ORYX vendors, based on contractual language, are required to submit a hospital’s third and fourth quarter 2019 chart-abstracted data in January and April 2020, respectively, using their current vendor data submission processes.

9


Changes to chart-abstracted submission requirements

• For CY 2020 chart-abstracted data and beyond, all hospitals submitting data transition to and use the Joint Commission Direct Data Submission Platform

• Hospitals collect and report monthly chart-abstracted aggregate data on a quarterly basis for CY 2020 using the Joint Commission’s DDSP

• In early 2020, The Joint Commission will provide additional information concerning the transition to the DDS Platform for chart-abstracted measures

10


• Freestanding psychiatric Hospital Accreditation Program reporting requirements:

• Continue to report on the four required Hospital-Based Inpatient Psychiatric Services (HBIPS) measures: HBIPS-1, HBIPS-2, HBIPS-3 and HBIPS-5.

2020 ORYX® Performance Measurement Requirements Hospitals with modified requirements

11


• Critical access hospitals, small hospitals (ADC ≤ 10) and ORYX-designated specialty hospitals continue to report on a choice of three available measures (selected measures can be chart-abstracted or eCQM).

• These hospitals remain exempt from requirement to submit data to The Joint Commission.

• If data are not submitted, the organization is required to make data reports available for review by surveyors during on-site surveys.

2020 ORYX® Performance Measurement Requirements Hospitals with modified requirements

12



Hospitals with modified requirements

• Hospital Accreditation Programs (HAP) for which ORYX Performance Measure Reporting Requirements continue to be suspended:

• freestanding children’s hospitals

• long-term acute care hospitals

• inpatient rehabilitation facilities

13



Summary of ORYX eCQM Requirements:

• 2019 ORYX eCQM reporting requirements:o Minimum of 4 eCQMs (13 available)o Minimum of 1 self-selected calendar quartero For CY 2019 eCQM data and forward, all hospitals transition to and use the

Direct Data Submission (DDS) Platform

• 2020 ORYX eCQM reporting requirements:o a minimum of 4 eCQMs (10 available)o a minimum of 1 self-selected calendar quartero All hospitals use DDS Platform for eCQM data submission

14


⎻ eAMI-8a Primary PCI Received Within 90 Minutes of Hospital Arrival (Retired CY2020)

⎻ eCAC-3 Home Management Plan of Care Document Given to Patient/Caregiver (Retired CY2020)

⎻ eED-1 Median Time from ED Arrival to ED Departure for Admitted ED Patients (Retired CY2020)

⎻ eED-2 Admit Decision Time to ED Departure Time for Admitted Patients

⎻ eEHDI-1a Hearing Screening Prior to Hospital Discharge (Retired CY2020)

⎻ ePC-01 Elective Delivery (Retained CY2020)

⎻ ePC-02 Cesarean Birth (Adopted as of 1/1/2020 discharges)

⎻ ePC-05 Exclusive Breast Milk Feeding

⎻ eSTK-2 Discharged on Antithrombotic Therapy

⎻ eSTK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter

⎻ eSTK-5 Antithrombotic Therapy by End of Hospital Day Two

⎻ eSTK-6 Discharged on Statin Medication

⎻ eVTE-1 Venous Thromboembolism Prophylaxis

⎻ eVTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis

2020 ORYX® Performance Measurement Requirements Joint Commission 2020 eCQMs

15


2020 ORYX® Performance Measurement Requirements Alignment with CMS

• CMS extended the current eCQM submission and reporting requirements for CY 2020 reporting:

o Hospitals are required to submit data for 1, self-selected quarter on 4 self-selected eCQMs

• As finalized in the FY 2019 IPPS final rule:

o CMS will remove 7 eCQMs for CMS CY 2020 reporting, with 8 eCQMsavailable for selection.

16


ORYX Requirements:Questions

17


⎻ Question: What if my hospital cannot report on the required chart-abstracted measure (i.e., PC-01) as we do not provide obstetrical services?

⎻ Answer: Acute Care Hospitals not providing Obstetrical Services are not required to select an alternate chart-based measure.

Common QuestionsHospitals with an ADC > 10 required chart-abstracted measures

18


⎻ Question: Have any chart-based measures been retired for 2020 ORYX reporting requirements?

⎻ Answer: Effective with January 1, 2020 two measures have been retired for accreditation and certification purposes.

− Retired Measures:

• PC-03 Antenatal Steroids

• PC-04 Health-Care Associated Bloodstream Infections in Newborns

Common QuestionsRetired measures

19


⎻ Question: For 2020, is the Joint Commission retiring the three chart-abstracted measures that CMS previously removed for CY 2019 reporting (i.e., ED-1, IMM-2 and VTE-6)?

⎻ Answer: The Joint Commission has not retired the measures.

• ED-1, IMM-2 and VTE-6 remain on the list of Additional Joint Commission Chart-Abstracted Measures available for selection

− CAHs, small (ADC ≤ 10) and ORYX designated specialty hospitals may select the measures to meet their ORYX requirements

− Hospitals with an ADC > 10 wishing to report additional measures beyond their required PC-01 chart-abstracted measure may select from these measures.

Common QuestionsCMS previously removed chart-abstracted measures

20


⎻ Question: If I continue to use a vendor to assist with my chart-abstracted measure submission, how does my vendor stay abreast of items such as measure specifications, data aggregation, etc.

⎻ Answer: Hospitals are responsible for the data submission process and the relationships with users they have invited onto their DDS Platform Workspace, including vendors.

• To facilitate this, hospitals may share webinar/educational material.

• The Joint Commission is also considering additional communication mechanisms to assist HCOs with chart-abstracted measures.

Common QuestionsChart-abstracted measures

21


⎻ Question: Can a hospital use the same eCQMs being submitted to CMS to meet the Joint Commission’s 2020 ORYX requirements?

⎻ Answer: Eight of the ten eCQMs offered by The Joint Commission for 2020 ORYX

measure reporting are in alignment with CMS and utilize the same measure specifications:

• eED-2 Admit Decision Time to ED Departure Time for Admitted Patients

• ePC-01 Elective Delivery (TJC retained; CMS removed)

• ePC-02 Cesarean Birth (TJC adopted as of 1/1/2020 discharges; CMS does not offer)

• ePC-05 Exclusive Breast Milk Feeding

• eSTK-2 Discharged on Antithrombotic Therapy

• eSTK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter

• eSTK-5 Antithrombotic Therapy by End of Hospital Day Two

• eSTK-6 Discharged on Statin Medication

• eVTE-1 Venous Thromboembolism Prophylaxis

• eVTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis

Common Questions2020 ORYX eCQMs

22


⎻ Question: Where do we find 2020 eCQM specifications?

⎻ Answer:− Information regarding The Joint Commission’s eCQM specifications developed

by The Joint Commission or that will be maintained by The Joint Commission following removal by CMS (i.e. ePC-01 and ePC-02), can be found via the “Measurement” link under Specifications at:

• https://www.jointcommission.org/performance_measurement.aspx

− For specifications related to all remaining eCQMs in alignment with CMS, see the CMS/ONC eCQI Resource Center at

• https://ecqi.healthit.gov/qrda-quality-reporting-document-architecture

Common Questions2020 eCQM Specifications

https://www.jointcommission.org/performance_measurement.aspx

https://ecqi.healthit.gov/qrda-quality-reporting-document-architecture

23


⎻ Question: How does my hospital make their 2020 ORYX chart-based measure selections?

⎻ Answer: In early 2020, The Joint Commission will provide information regarding CY 2020 chart-based measure selections.

⎻ Question: How does my hospital make their 2020 ORYX eCQM selections?

⎻ Answer: Users of the DDS Platform use the functionality within the Platform to select their eCQMs at time of submission.

Common Questions

2020 ORYX Chart-Based Measure and eCQM Selections

24


⎻ Question: For CY 2020, are CAHs, small hospitals and ORYX Designated Specialty hospitals required to submit data using the DDS Platform?

⎻ Answer: These hospitals remain exempt from the requirement to submit data to The Joint Commission, but are encouraged to do so. If data are not submitted, the organization is required to make data reports available for review by surveyors during on-site surveys.

− Hospitals that choose to submit, report monthly aggregate data on a quarterly basis for calendar year (CY) 2020 using The Joint Commission DDS Platform.

Common Questions2020 ORYX Measure Reporting

25


⎻ Question: For CY 2020, are Freestanding Psychiatric Hospitals required to submit data using the Direct Data Submission (DDS) Platform?

⎻ Answer: Starting with CY 2020, Freestanding Psychiatric Hospitals will use The Joint Commission DDS Platform to submit monthly aggregate data on a quarterly basis on the four HBIPS chart-abstracted measures

Common Questions

2020 ORYX Freestanding Psychiatric Hospital Reporting

26


⎻ Question: Do you have file layout for ORYX data submission for the new direct data submission platform to submit HBIPS data, rather than going through a 3rd

party vendor?

⎻ Answer: In early 2020, The Joint Commission will provide additional information regarding data submission on the DDS Platform to al hospitals.

Common Questions

2020 ORYX Freestanding Psychiatric Hospital Reporting

27


⎻ Question: With the change to aggregate data submission for CY 2020, will my hospital still receive an ORYX Performance Measure Report (PMR)?

⎻ Answer: The Joint Commission will continue to display chart-abstracted measure data and hospital performance on the chart-abstracted measures in the ORYX Performance Measure Report (PMR) provided to the hospital.

Common Questions

2020 ORYX Reporting

28


Direct Data Submission

29


eCQMs

Direct Data Submission

ORYX Vendor

TJC ORYX Vendor Portal

Direct Data Submission Platform – CY2019 data

Chart Abstracted Measures

Data Submission using an ORYX Vendor

HCOs Submitting Data

TJC Data Warehouse

30


Direct Data Submission for BOTH eCQMs and Chart Abstracted Measures

TJC Data Warehouse

Direct Data Submission Platform – CY2020 data

HCOs Submitting Data

Note: eCQM QRDA I documents submitted on an annual basis chart-abstracted monthly aggregate data submitted on a quarterly basis

31


Direct Data Submission:Common Questions

32


Data Submission

Question: What is the timeframe for using the DDS Platform for data submission of eCQMs and chart-abstracted measure data?

Answer:

⎻ CY 2019 eCQM data submission

• No ORYX eCQM vendor contracts

• All hospitals use the Direct Data Submission Platform for submission of eCQMs

⎻ CY 2020 eCQM and chart-abstracted measure data submission

• No ORYX eCQM or ORYX chart-abstracted vendor contracts

• All hospitals use the Direct Data Submission Platform for submission of eCQMs and chart-abstracted data

33


Vendors/Consultants on the Platform

Question: Please clarify the role vendors / consultants may play in assisting clients on the Direct Data Submission Platform.

Answer:

⎻ Starting CY2020, The Joint Commission does not have contracts with ORYX vendors.

⎻ HCO staff using the DDS Platform are responsible for their relationships with users on the Platform. Each hospital/system needs to define their own privacy and security policies regarding the DDS Platform.

⎻ HCOs are responsible for vendor/consultant training as it relates to the Platform. To facilitate this, they may share webinar/educations material.

⎻ HCOs may choose to work with a vendor or consultant that assists them with their data upload and data verification processes. If that is the case, HCOs are responsible for inviting the respective vendor/consultant to the platform.

34


Vendors/Consultants on the Platform (cont.)

Answer (cont.):

⎻ Hospital staff using the Joint Commission’s DDS Platform can grant external user permissions to assist with functionality such as:

− Chart-based – assist with data collection and data aggregation and other needed functionality. In early 2020 additional detail will be provided on submission processes, onboarding and usage of the Direct Data Submission Platform.

− eCQMs - uploading QRDA I documents or the data verification process (e.g., correct QRDA I generation based on error/warnings, review measure results and rates to assist with data mapping issues).

35


⎻ Question: How is the DDS Platform accessed?

⎻ Answer: Information regarding access to the DDS Platform is communicated directly to hospitals as they are on-boarded to the Platform.

Common QuestionsDirect Data Submission Platform

36


ORYX Performance Measurement Billing

37


ORYX Program Annual Fee

− Beginning in January 2019, HCOs with ORYX requirements were billed an annual fee based upon organizational weighted volumes for both eCQMs and chart-based submissions.

− The ORYX Program annual fees is billed on a separate line of the January 2020, annual fee invoice


38


ORYX Performance Measurement Billing:

Questions

39


⎻ Question: Does the annual fee only apply to the hospital and critical access accreditation programs with ORYX requirements?

⎻ Answer: The ORYX program annual fee applies to organizations with ORYX performance measurement reporting/submission requirements. Any organizations currently excluded from ORYX reporting/submission will not have a performance measurement annual fee.

Common QuestionsORYX Program Annual Fee

40


Certification Standardized Measures

41


Certification Standardized Measurement Requirements Data Submission Process - Update

• The Joint Commission Advanced Certification Programs currently using an ORYX chart-based vendor to submit certification measures will be transitioned to manual entry of their aggregate data using the Certification Measure Information Process (CMIP) application available on JC Connect.

• The advanced certification programs include

• Acute Stroke Ready Hospital (ASRH)

• Primary Stroke Center (PSC)

• Thrombectomy-capable Stroke Center (TSC)

• Advanced Comprehensive Stroke Center (CSC-A)

• Perinatal Care (PNC)

42


Common Questions:

Certification Standardized Measures

43


⎻ Question: For certification programs with standardized measures, may we use an ORYX chart-based vendor for submission of data?

⎻ Answer: Starting with CY 2020 data, The Joint Commission no longer has contracts with ORYX chart-based vendors for certification or accreditation purposes.

⎻ All hospitals in the Acute Stroke Ready Hospital (ASRH), Primary Stroke Center (PSC), Thrombectomy-capable Stroke Center (TSC), Advanced Comprehensive Stroke Center (CSC-A), and Perinatal Care (PNC) certification programs that have been using an ORYX chart-based vendor will be transitioned to manually entering their aggregate data on the Certification Measure Information Process (CMIP) application available on JC Connect.

Common QuestionsCertification

44


⎻ Question: May a hospital use a vendor to assist them in data collection and aggregation for standardized measures?

⎻ Answer: Yes, a hospital may utilize the services of a vendor or consultant to assist them in data collection and/or aggregation to prepare the hospital to manually report their aggregate data via the Certification Measure Information Process (CMIP) application available on JC Connect.


45


⎻ Question: For certification purposes, can we use eCQMs?

⎻ Answer: At this time, The Joint Commission is not using eCQMs for certification program purposes. Data must be reported on the standardized chart-abstracted measures.


46


Resources



47


What you need to know about Joint Commission 2020 ORYX® Performance Measurement Requirements



48


This document contains three sections:

1. ORYX® Accreditation Reporting Requirements

a. General

b. Hospitals (HAP) with An Average Daily Census (ADC) of greater than 10 inpatients

c. Small Hospitals (HAP with ADC ≤ 10) and Critical Access Hospitals (CAH)

d. Inpatient Psychiatric Facilities (HAP) - Freestanding Psychiatric Hospitals and Inpatient Psychiatric Units

e. Specialty Hospitals

f. Hospitals (HAP) with suspended ORYX requirements

2. Electronic Clinical Quality Measures (eCQMs)

a. General

b. Direct Data Submission (DDS)

1. General and Onboarding

2. Education, Technical Information, and Using the Platform

3. Certification Standardized Measures

a. General

Attachment A – CY 2019 AND 2020 REPORTING PERIOD: ECQM VERSIONS, HL7 STANDARDS, EHR CERTIFICATION

VERSION, AND CMS IMPLEMENTATION GUIDES

What you need to know: Frequently Asked Questions (FAQs)


49



ATTACHMENT A

CY 2019 AND 2020 REPORTING PERIOD

ECQM VERSIONS, HL7 STANDARDS, EHR CERTIFICATION VERSION, AND CMS IMPLEMENTATION GUIDES The Joint Commission aligns with CMS on their eCQM versions, HL7 standards, EHR Certification Version, and CMS

Implementation Guide. The below documents this alignment.

To access the HL7 standards, EHR Certification information, and CMS Implementation Guides, please visit

CMS/ONC’s eCQI Resource Center at https://ecqi.healthit.gov/.

See the appropriate website to access the eCQM Specifications, information on reading and understanding the

specifications; including Implementation Checklists, Guide for Reading eCQMs, eCQM Measure Logic Guidance,

Technical Release Notes, and eCQM Flows:

• The Joint Commission’s ePC-01 and ePC-02 eCQM specifications and related information, can be found at

the “Measurement” link under Specifications

(https://www.jointcommission.org/performance_measurement.aspx).

• Specifications and related information for all remaining eCQMs in alignment with CMS, are available at the

CMS/ONC’s eCQI Resource Center (https://ecqi.healthit.gov/qrda-quality-reporting-document-architecture).

Note: Please be sure when using the eCQI Resource Center, that you have select the appropriate Reporting Period

and click ‘Applied’.

CY 2019 and CY 2020 eCQM Specifications, HL7 Standards,

EHR Certification Versions, and CMS Implementation Guides Patients discharged during the

calendar year (CY)

2019 2020

eCQM data submission deadline CMS: 3/2/2020

Joint Commission: 3/16/2020

CMS: 3/1/2021

Joint Commission: 3/15/2021

Back

50


51



https://www.jointcommission.org/topics/pioneers_in_quality.aspx

https://www.jointcommission.org/topics/pioneers_in_quality.aspx

52


Upcoming Pioneers in Quality Events

53


Upcoming Pioneers in Quality Events

2020 Proven Practices Submission Launch

Submission window for 2020 Proven Practices Program

• Opens 1Q2020

• List serv announcement: online submission tool availability

• All who have registered for prior PIQ webinars receive email invitations to submit their pioneering eCQM Proven Practice

54


Save the Date:Pioneers in Quality eCQM Expert to Expert Series Webinar: ePC-01 & ePC-02

Upcoming Educational EventsPioneers in Quality

December 3 9:00-10:00 am (PT); 10:00-

11:00 am (MT); 11:00 am-

noon (CT); Noon-1:00 pm (ET)

If the “Register” button is not clickable, visit this url to register: https://goto.webcasts.com/starthere.jsp?ei=1261709&tp_key=30f88c1ac2

https://goto.webcasts.com/starthere.jsp?ei=1261709&tp_key=30f88c1ac2

https://goto.webcasts.com/starthere.jsp?ei=1261709&tp_key=30f88c1ac2

what you need to know about joint commission 2020 oryx ... · ⎻epc-01 elective delivery (retained...

Documents