The Joint Commission shifting ORYX to eCQMs
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The Joint Commission shifting ORYX to eCQMs

The Joint Commission requires electronic clinical quality measure (eCQM) reporting for the ORYX Performance Measurement program in 2017


On September 7, 2016, The Joint Commission finalized the 2017 ORYX Performance Measurement requirements continuing their commitment to remain closely aligned with the CMS Hospital Inpatient Quality Reporting (IQR) Program. The Joint Commission has elected not to adopt all of the electronic clinical quality measures (eCQMs) implemented by CMS. The list of eCQMs The Joint Commission selected includes 13 of 15 eCQMs to be implemented by CMS.

For 2017, The Joint Commission has eliminated the measure set reporting requirement.  Measure selection and reporting will be by individual measure. 

Summary of 2017 Joint Commission ORYX Measurement Requirements:

  • Report on 5 required chart-abstracted measures quarterly.
    • Hospitals with at least 300 live births will be required to report on all of the chart-abstracted perinatal care measures.
  • Report on 6 of 13 available electronic clinical quality measures (eCQMs) by March 15, 2018.
  • Performance measures must be submitted by a quality reporting vendor certified by The Joint Commission.
  • Critical Access Hospitals (CAHs) and Small Hospitals (ADC ≤ 10) will report on a choice of 6 available measures.

Hospital Accreditation Program Requirements for ORYX

Electronic Clinical Quality Measures (eCQMs)

Hospitals will be required to report on 6 of 13 available eCQMs applicable to the services provided and patient populations served by the hospital. In addition, hospital will need to report 4 quarters of data for calendar year (CY) 2017 by the annual submission date (3/15/2018).  Hospitals may elect to report on additional eCQMs relevant to services provided and patient populations served by the hospital – See The Joint Commission measures effective January 1, 2017.

The Joint Commission has finalized the following eCQMs:

  • AMI-8a - Primary PCI Received Within 90 Minutes of Hospital Arrival
  • CAC-3 - Home Management Plan of Care Document Given to Patient/Caregiver
  • ED-1 - Median Time from ED Arrival to ED Departure for Admitted ED Patients
  • ED-2 - Admit Decision Time to ED Departure Time for Admitted Patients
  • PC-01 - Elective Delivery
  • PC-05 - Exclusive Breast Milk Feeding
  • STK-02 - Discharged on Antithrombotic Therapy
  • STK-03 - Anticoagulation Therapy for Atrial Fibrillation/Flutter
  • STK-05 - Antithrombotic Therapy by the End of Hospital Day Two
  • STK-06 - Discharged on Statin Medication
  • VTE-1 - Venous Thromboembolism Prophylaxis
  • VTE-2 - Intensive Care Unit Venous Thromboembolism Prophylaxis
  • EHDI-1a - Hearing Screening Prior to Hospital Discharge

Chart-Abstracted Measures

Hospitals will need to report on 5 chart-abstracted measures applicable to the services provided and patient populations served by the hospital. Chart-abstracted measures must be collected and reported quarterly for calendar year (CY) 2017.  The Joint Commission has not adopted the CMS "sepsis management bundle" (SEP-1) and has removed STK-08 - Stroke Education, and STK-10 - Assessed for Rehabilitation from the measure selection.

The Joint Commission has finalized the following Chart-Abstracted Measures:

  • ED-1 - Median Time from ED Arrival to ED Departure for Admitted ED Patients
  • ED-2 - Admit Decision Time to ED Departure Time for Admitted Patients
  • PC-01 - Elective Delivery
  • VTE-6 - Incidence of Potentially Preventable VTE
  • IMM-2 - Influenza Immunization Measure

Reporting on 4 additional Perinatal Care measures (PC-02, PC-03, PC-04, PC-05) is required for health care organizations with at least 300 live births per year.

  • PC-01 - Elective Delivery
  • PC-02 - Cesarean Section
  • PC-03 - Antenatal Steroids
  • PC-04 - Health Care-Associated Bloodstream Infections in Newborns
  • PC-05 - Exclusive Breast Milk Feeding

Critical Access Hospitals and Small Hospitals for ORYX (ADC of 10 or fewer inpatients)

Electronic Clinical Quality Measures (eCQMs) / Chart-Abstracted Measures

Critical access hospitals and small hospitals must report on a total of 6 measures applicable to the services provided and patient populations served by the hospital from a combination of the finalized chart-abstracted measures and eCQMs below:

Joint Commission Chart-Abstracted Measures:

  • ED-1, ED-2
  • PC-01, PC-02, PC-03, PC-04, PC-05
  • VTE-6
  • IMM-2
  • HBIPS-1, HBIPS-2, HBIPS-3, HBIPS-5
  • TOB-1, TOB-2, TOB-3 SUB-1, SUB-2, SUB-3
  • OP-18, OP-20, OP-21, OP-23

Joint Commission eCQM Measures:

  • eAMI-8a
  • eCAC-3
  • eED-1, eED-2
  • ePC-01, ePC-05
  • eSTK-2, eSTK-3, eSTK-5, eSTK-6
  • eVTE-1, eVTE-2
  • eEHDI-1a

https://www.jointcommission.org/assets/1/18/2017_ORYX_Reporting_Requirements.pdf  

The Joint Commission requires that electronic clinical quality measures (eCQM) be submitted by a quality reporting vendor certified by the Joint Commission. Acmeware has met the criteria for inclusion in the certification process and is included on The Joint Commission’s list of acceptable ORYX vendors. Acmeware is committed to meeting future required criteria established by The Joint Commission.

Last year, Acmeware was 1 of only six vendors submitted eCQMs to the Joint Commission on behalf of a hospital.

Acmeware will work with your organization to assists in meeting CMS and The Joint Commission measurement specifications for performance monitoring and data collection with a single solution. We will help identify areas for new system changes or enhancements to existing systems based on data collected.

Acmeware utilizes OneView to extract data from the MEDITECH Data Repository and import it to the CMS Abstraction & Reporting Tool, CART. Through data collection, retrospective analyses and real-time reporting, CART and OneView together enable hospitals to comprehensively evaluate and manage quality improvement efforts. Whether a hospital is seeking Medicare certification and/or Joint Commission accreditation, or undertaking its own quality improvement initiatives, CART and OneView are ideal for the data collection and analyses that are essential to the success of all quality improvement efforts.

 

For more information on how Acmeware can serve your ORYX needs, please visit: joint-commission-oryx-vendor.aspx


By Bill Presley at 20 Sep 2016, 15:59 PM
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