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.
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, hospitals 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
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
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:
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
- 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
Opportunities and Challenges
The Joint Commission requires that electronic clinical quality measures (eCQM) be submitted by a quality reporting vendor certified by the Joint Commission. Acmeware is an approved ORYX vendor for eCQMs. Acmeware continues to lead the way in clinical quality measure reporting and remains committed to working hospitals and physicians as they prepare for The Joint Commission ORYX Performance Measurement Reporting in their efforts to meet eCQM reporting requirements.
Last year, Acmeware was 1 of only six vendors submitted eCQMs to the Joint Commission on behalf of a hospital. This accomplishment demonstrates our long-term commitment to quality reporting and highlights why healthcare organizations are partnering with Acmeware to improve care quality and outcomes by using OneView as a single integrated quality reporting platform.
Trust is an important factor in determining an ORYX vendor partnership. As a trusted partner in Quality Reporting, Acmeware takes the responsibility of submitting ORYX measures to The Joint Commission.
