Essentially there are three major changes you should be aware of for 2020 reporting. In addition to the changes, there are annual requirements you'll need to meet in order to successfully report. To help you better understand what is required, we've created a video summary for you to watch.
The Joint Commission is moving away from patient-level data submission and moving to aggregate data submission. This is only applicable for your chart-abstracted measure submission. So, each quarter, a hospital must submit their monthly performance at the aggregate level instead of the patient-level data.
2. Submission method
All of your hospital’s data, for both chart-abstracted and eCQMs, must be submitted via the DDS platform. The DDS platform is The Joint Commission’s Direct Data Submission platform.
If you’re a Medisolv client, don’t panic. Nothing changes for you. Medisolv will still submit all of your data, both abstracted and electronic, as we always do. Hospitals must simply authorize their vendor to submit on their behalf and we take care of submitting your data.
3. Measure lists
Usually we have found that TJC tries to align their measure lists with the CMS programs, but over the course of the last few years things have diverged. There are 23 active abstracted measures and 10 active eCQMs that you see on your screen there. Many of the previous measures have been retired.
Also read: 2020 Joint Commission ORYX® Requirements
2020 program requirements
Chart-abstracted measure requirements
The Joint Commission has narrowed the list of required chart-abstracted measures to one; PC-01, unless you are a hospital with 300 or more births or a free-standing psych hospital.
| Chart-abstracted measure |
| PC-01 |
The PC-01 measure is to be submitted on a quarterly basis for the entire 2020 calendar year. And remember it’s only aggregate monthly data that needs submitted.
Remember, due to COVID-19, The Joint Commission has made Quarter 1 and Quarter 2 chart-abstracted data submission optional. But, if you do choose to submit, TJC has extended the submission deadline.
• Quarter 1 2020 deadline extended from July 31, 2020 to Oct. 31, 2020.
• Quarter 2 2020 deadline extended from Oct. 31, 2020 to Jan. 31, 2021.
eCQM requirements
The eCQM reporting requirements will remain the same. In 2020, hospitals must continue to submit four of the available 10 eCQMs. You must report on one self-selected quarter from 2020. The deadline to submit your measures is March 15, 2021.
| eCQMs |
| ED-2 |
STK-3 |
| PC-01 |
STK-5 |
| PC-02 (NEW) |
STK-6 |
| PC-05 |
VTE-1 |
| STK-2 |
VTE-2 |
The difference this year, is the available measure list. TJC added a brand-new eCQM, ePC-02 (Cesarean Birth). They also retired the following eCQMs: AMI-8a, CAC-3, ED-1 and EHDI-1a.
Also read: The Joint Commission reveals new eCQM
Just like the abstracted measures, this data must be submitted via the DDS platform, although this isn’t new for eCQMs. This was a requirement in 2019. However, unlike the abstracted measures, eCQMs must still contain patient-level data in the form of a QRDA I file format.
Special facility requirements
Hospitals with at least 300 births per year are required to submit three additional perinatal care abstracted measures (PC-02, PC-05 and PC-06) in addition to the PC-01 measure.
Freestanding psychiatric hospitals
In 2020, freestanding psychiatric hospitals must continue to report on the four Hospital-Based Inpatient Psychiatric Services (HBIPS) chart-abstracted measures below. Just as with your chart-abstracted measures, aggregate data must be submitted on a quarterly basis for the entire 2020 calendar year using the DDS platform.
| HBIPS |
| HBIPS-1 |
| HBIPS-2 |
| HBIPS-3 |
| HBIPS-5 |
Critical access and small hospitals
Critical access and small hospitals with an average daily consensus of 10 or fewer inpatients are required to collect data on any three measures from either the chart-abstracted or eCQM options below. Measures can be a combination of both types.
| Chart-Abstracted Measures |
eCQMs |
| ED-1, ED-2 |
ED-2 |
| PC-01, PC-02, PC-05, PC-06 |
PC-01, PC-02, PC-05 |
| VTE-6 |
STK-2, STK-3, STK-5, STK-6 |
| IMM-2 |
VTE-1, VTE-2 |
| HBIPS-1, HBIPS-2, HBIPS-3, HBIPS-5 |
|
| TOB-2, TOB-3 |
|
| SUB-2, SUB-3 |
|
| OP-18, OP-23 |
|
Just as before, these hospitals are exempt from the requirement to submit, but the reports must be available for review by surveyors during on-site surveys. If you do submit, it must be monthly aggregate data on a quarterly basis using the DDS platform.
Facilities with suspended requirements
As in the past, the following facilities are exempt from The Joint Commission ORYX® requirements in 2020:
- Freestanding Children’s Hospitals
- Long Term Acute Care Hospitals
- Inpatient Rehabilitation Facilities
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