Pioneers in Quality™ 2019 Joint - jntcm.ae-admin.com · ⎻All hospitals submitting eCQM data for CY2019 will be transitioned to the DDS Platform beginning with CY 2019 data and

Pioneers in Quality™ 2019 Joint

Commission ORYX® Reporting

Requirements: Your Questions Answered

Tricia Elliott, MBA, CPHQ

Director, Quality MeasurementOctober 23, 2018

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© 2018, The Joint Commission

Pioneers in Quality

2019 Joint Commission ORYX Reporting Requirements: Your Questions Answered

Today’s presentation is focused on…

• 2019 Chart-based and eCQM data collection and reporting requirements for accredited hospitals and hospitals with modified requirements (critical access, small and freestanding psychiatric hospitals).

• Direct Data Submission for eCQMs

• ORYX Performance Measurement Pricing/Billing

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2019 ORYX Requirements

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Alignment with CMS

• CMS maintained its CY 2018 eCQM reporting requirements and currently available eCQMs for CY 2019

• Hospitals are required to report on four eCQMs for one self-selected calendar quarter.

• CMS removed three chart-abstracted measures in common with The Joint Commission effective for the CY 2019 reporting period, ED-1, IMM-2 and VTE-6.

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2019 ORYX Reporting Requirements

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2019 ORYX Reporting Requirements

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Joint Commission ORYX Chart-based

• Hospitals* with an ADC > 10 report on 2 required chart-abstracted measures

o ED-2 Admit Decision Time to ED Departure Time for Admitted Patients

o PC-01* Elective Delivery

• Reduced from 5 measures

• Applicable to the services provided and populations served

*Hospitals with at least 300 live births per year are required to report on all of the chart-

abstracted perinatal care measures, including PC-06 effective with 1/1/2019 discharges.

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Joint Commission ORYX Chart-based

• Monthly chart-abstracted measure data must continue to be reported on a quarterly basis for all four calendar quarters of 2019 utilizing an ORYX chart-based vendor.

• The Joint Commission continues to utilize ORYX vendors for submission of hospitals’ chart-based data through 2019 and the use of vendors will be evaluated annually thereafter.

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Joint Commission ORYX eCQM Requirements

• 2018 ORYX eCQM reporting requirements:

o a minimum of four eCQMso a minimum of one self-selected calendar quartero Two data submission methods available; thru an ORYX vendor or the

Direct Data Submission (DDS) Platform

• 2019 ORYX eCQM reporting requirements:

o a minimum of four eCQMso a minimum of one self-selected calendar quartero For CY 2019 eCQM data and forward, all hospitals will be

transitioned and utilize the DDS Platform

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Joint Commission ORYX eCQM Requirements

⎻ As of July 2018, The Joint Commission invited all Joint Commission-accredited hospitals with CY 2018 ORYX eCQM reporting requirements to transition to direct data submission platform.

⎻ All hospitals submitting eCQM data for CY2019 will be transitioned to the DDS Platform beginning with CY 2019 data and forward.

NOTE: Hospitals can expect additional communication and instruction from The Joint Commission in 2019 regarding the transition to the Direct Data Submission (DDS) Platform.

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Hospitals with modified requirements

⎻ Critical Access Hospitals (CAHs) and Small Hospitals (ADC ≤ 10):

• choice of 3 available measures (reduction from 6 to 3 measures).

• Combination of chart-based and/or eCQMs

⎻ Freestanding Psychiatric Hospitals:

• Continue to report on the 4 required Hospital-Based Inpatient Psychiatric Services (HBIPS) measures.

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Hospitals with modified requirements

⎻ Suspension of requirements continue:

• freestanding children’s hospitals,

• long term acute care hospitals,

• inpatient rehabilitation facilities.

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Common Questions:

ORYX Requirements

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⎻ Question: What if my hospital cannot report on the required 2 chart-abstracted measures (i.e., ED-2 and PC-01) as they are not applicable to our services provided and patient populations?

⎻ Answer: Hospitals that do not provide the service or serve the patient population addressed by ED-2 and/or PC-01 will not be required to select an alternate measure.

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

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⎻ Question: Have any chart-based measures been retired or added for 2019 ORYX reporting requirements?

⎻ Answer: Effective with January 1, 2019 discharges, one measure is being added and 2 measures will be retired for accreditation purposes.

− New Measure:

• PC-06 Unexpected Complications in Term Newborns

− Retired Measures:

• TOB-1 Tobacco Use Screening

• SUB-1 Alcohol Use Screening

Common QuestionsNew or retired measures

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

⎻ Answer: The Joint Commission is not retiring ED-1, IMM-2 and VTE-6 for 2019.

• However, these measures are longer required for Hospitals with an ADC > 10

• ED-1, IMM-2 and VTE-6 will remain on the list of Additional Joint Commission Chart-Abstracted Measures Available for Selection.

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

− Hospitals with an ADC > 10 may select additional chart-abstracted measures for reporting in CY 2019 beyond the two required chart-abstracted measures.

Common QuestionsCMS removal three chart-abstracted measures

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⎻ Answer:

⎻ • eAMI-8a Primary PCI Received Within 90 Minutes of Hospital Arrival

⎻ • eCAC-3 Home Management Plan of Care Document Given to Patient/Caregiver

⎻ • eED-1 Median Time from ED Arrival to ED Departure for Admitted ED Patients

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

⎻ • eEHDI-1a Hearing Screening Prior to Hospital Discharge

⎻ • ePC-01 Elective Delivery

⎻ • 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 QuestionseCQMs available for 2018/2019 selection

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⎻ Question: How does my hospital make their 2019 ORYX chart-based measure selections*?

⎻ Answer: In early November 2018, a chart-based measure selection form will be available

on our website https://www.jointcommission.org/performance_measurement.aspxfor hospitals with an ADC > 10

▪ Return the form only if you want to reduce or change your currently selected chart-abstracted measures for 2019

▪ The form is due mid-December 2018

*2019 Requirements: Effective with January 1, 2019 discharges, the chart-based ED-2 and PC-01 measures are required, and submitted on a quarterly basis via an ORYX chart-based vendor. If your total Live Births >= 300, then PC-02, 03, 04, 05, and 06 are also required.

Common Questions2019 ORYX Chart-Based Measure Selections: Hospitals with an ADC > 10

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

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⎻ Question: How will my 2019 eCQM data* be submitted to The Joint Commission?

⎻ Answer: Starting with 2019, all eCQM data being submitted to The Joint Commission via our Direct Data Submission (DDS) Platform.

• In 2019, following the March 2019 submission deadline of CY 2018 eCQM data, additional communication and instructions will be shared regarding the transition to the DDS Platform.

• No action required until you receive the above communication

*2019 eCQM Requirements:

• Hospitals with an ADC > 10 are required to submit data on a minimum of four eCQMs for a minimum of one self-selected calendar quarter.

Common Questions2019 Submission of eCQM Data: Hospitals with an ADC > 10

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⎻ Question: How does my hospital make their 2019 ORYX measure selections*?

⎻ Answer: In early November 2018, a measure selection form will be available on our website https://www.jointcommission.org/performance_measurement.aspx for CAHs, Small Hospitals, and ORYX designated specialty hospitals

▪ Form must be returned to confirm measure selections for 2019

▪ In addition, the form will be used to select data submission method

➢ Chart-based measures: self-report or ORYX Vendor

➢ eCQMs: self-report or Direct Data Submission (DDS) Platform▪ The form is due mid-December 2018

*2019 Requirements: Effective with January 1, 2019 discharges, these hospitals must choose a minimum of 3 available measures (reduction from 6 measures). These measures will be selected from chart-abstracted measures and/or eCQMs.

Common Questions2019 ORYX Measure Selections: CAHs, Small Hospitals (ADC <= 10) and ORYX designated specialty hospitals


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⎻ Question: Can we update our measure selections within the ORYX Measure Selection (OMS) application on Joint Commission Connect?

⎻ Answer: The OMS application is closed to external users for updating.

• The Joint Commission makes all measure selection changes within the OMS application.

• Contact [email protected] if you have questions regarding ORYX selection changes.

Common QuestionsORYX Measure Selections

mailto:[email protected]

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ORYX 2018 Requirements

2018 ORYX eCQM Selection Form

2018 ORYX eCQM Selection

forms are due to The Joint

Commission no later than

October 31, 2018.

REMINDER

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eCQM Direct Data Submission

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Data Submission with an ORYX eCQM Vendor

ORYX Vendor

TJC ORYX Vendor Portal

TJC Data Warehouse

HC

Os

wit

h E

HR

(s)


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Direct Data Submission

TJC Data Warehouse

HC

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h E

HR

(s)


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Verification

Powered by Apervita

Direct Data Submission Platform

Upload Data

Data Accuracy

Quality Improvement

Deidentification

Submit Data

DataData

(Stripped of unwanted PHI)

ANALYTICS

RESULTS ANALYTICS DASH- BOARDS

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Verification

Powered by Apervita


Upload Data

Data Accuracy

Quality Improvement

Deidentification

Submit Data

DataData


ANALYTICS


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Verification

Powered by Apervita


Upload Data

Data Accuracy

Quality Improvement

Deidentification

Submit Data

DataData


ANALYTICS


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Verification

Powered by Apervita


Upload Data

Data Accuracy

Quality Improvement

Deidentification

Submit Data

DataData


ANALYTICS


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The Joint Commission Direct Data Submission

Platform – Powered by Apervita

Key benefits of the platform:

✓ 24/7 access during the submission period, ✓ Easy to use data visuals, ✓ Cloud-based platform environment with fast file transfer, ✓ Robust security and HIPAA compliance, ✓ State of the art rules engine, ✓ Transparency

HCOs have the ability to see results and outcomes prior to the final submission step of submitting data to The Joint Commission.

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Common Questions:

eCQM Direct Data Submission

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⎻ Question: How is the DDS Platform accessed?

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

Common QuestionsDirect Data Submission Platform

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⎻ Question: May a hospital invite an external user (e.g., vendor or consultant) to assist them on the DDS Platform?

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

⎻ Hospital staff using the Joint Commission’s DDS Platform are responsible for the data submission process and the relationships with users on the DDS Platform. Any contract an ORYX vendor may have with The Joint Commission does not extend to the DDS Platform.

Common QuestionsDirect Data Submission Platform

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ORYX Performance Measurement Billing

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Billing Process

⎻ Historically, data transmission fees were billed to the ORYX Vendors based

upon the number of HCOs and types measures submitted.

• In 2017, the fee structure changed to a flat fee model for both eCQMs and chart-based

measures.

⎻ Joint Commission needed to transform the transmission and billing fees for

the ORYX program.

− Starting in January 2019, HCOs with ORYX requirements are billed an annual

fee based upon organizational weighted volumes for performance

measurement (both eCQMs and chart-based submission).


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Common Questions:

ORYX Performance Measurement Billing

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⎻ Question: How will my hospital be billed for the ORYX annual fee, beginning in 2019?

⎻ Answer: ORYX annual fees will be billed as a separate line item on the January 2019 accreditation annual fee invoice, for organizations with ORYX requirements..

Common QuestionsNew billing model

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⎻ Question: Beginning in January 2019, what ORYX reporting periods will be covered by the annual fee?

⎻ Answer: Any data due after January 2019 is covered by the annual fee.

• For 2019, the annual fee will include 2018 eCQM data due March 15, 2019 and chart-abstracted data will include 3rd and 4th quarter 2018 and 1st and 2nd quarter 2019 which are due January 31, April 30, July 31 and October 31, 2019, respectively.

• Beginning in January 2019, there will no longer be any transmission fees billed to the ORYX vendor for eCQMs or chart-based measures for accreditation or certification purposes

• Note: The last chart-based data transmission fees to be billed to ORYX vendors will be for 2Q18 data due October 31, 2018.


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

⎻ Answer: The new performance measurement billing model only applies to organizations with ORYX performance measurement reporting requirements. Any organizations currently excluded from ORYX reporting/submission will not have an associated performance measurement annual fee.


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Resources

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Pioneers in Quality Webinar Session

• Clinical Quality Language (CQL) Basics for Hospitals and Critical Access Hospitals – Thursday, November 29, 11:00 AM - 12:00 PM (CT). Registration will be available in late October.

Upcoming Educational EventsPioneers in Quality

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• CQL Expert to Expert Series will offer a deep dive into each individual eCQM’s CQL expression language.

• Visit the Expert to Expert landing page for additional information and, when available, to register. https://www.jointcommission.org/piq_expert_to_expert_series/

Upcoming Educational EventsPioneers in Quality

https://www.jointcommission.org/piq_expert_to_expert_series/

Documents

Pioneers in Quality™ 2019 Joint - jntcm.ae-admin.com · ⎻All hospitals submitting eCQM data for CY2019 will be transitioned to the DDS Platform beginning with CY 2019 data and