Pioneers in Quality: Pioneers in Quality 2019 Joint Commission ORYX Reporting Requirements: Your Questions Answered October 23, 2018 Q & A Document

Transcription

1 Pioneers in Quality: Pioneers in Quality 2019 Joint Commission ORYX Reporting Requirements: Your Questions Answered October 23, 2018 Q & A Document QUESTION 1: Will there be a copy of the slides available? A: A webinar replay link, and the slide presentations will be available on The Joint Commission website within 7-10 business days of the webinar. QUESTION 2: If we signed in by our name / via as guest as directed, how to receive the CE units? A: CE/CME/CEU credits are available for the live audio only. Credits will not be available for webinar replays. To claim credits, you must have: Individually registered for the webinar through The Joint Commission website. Listened to the webinar in its entirety. Only those listening live on the day of the call will be eligible to receive credit. This is an educational program being offered exclusively to Joint Commission-accredited organizations. Completed a post-program evaluation/attestation. A link to the post-program evaluation/attestation will be sent to your registered hours after the webinar. After completion of the survey, you will receive a printable certificate available to download. Please note: The survey will close approximately 2 weeks after the live webinar. QUESTION 3: Is continuing education credit available for CJCP? A: Continuing education credits are not available for today s webinar for those with CJCP certification. QUESTION 4: What is due by October 31 for 2018 ORYX measure selections? A: 2018 ORYX ecqm selections were due by October 31, The form was to be completed to indicate a hospital s 2018 ecqm submission method (either Direct Data Submission Platform or ORYX ecqm vendor) and selection of the ecqms to be submitted (minimum of four ecqms are expected to be submitted for a minimum of one calendar quarter). QUESTION 5: Will we receive any verification that our 2018 ORYX ecqm measure selection was received? A: A confirmation will be received from HCOORYX@jointcommission.org. QUESTION 6: How is this information regarding deadlines communicated? I didn t receive anything on the 10/31 deadline. A: ORYX notifications are sent to the individuals documented within your hospital s Joint Commission Connect site. Notifications are primarily sent to the individual listed as the ORYX Contact, with additional notifications going to the Primary Accreditation and/or Certification Contact, 1

2 Chief Quality Officer, and CEO depending on the significance and/or subject of the notifications. If you are one of these contacts, please make sure you have not opted out of receiving communication via Joint Commission Connect (on the Security Admin page) and/or via clicking the One-Click Unsubscribe link at the bottom of s sent by QUESTION 7: Didn't we submit our 2018 ecqm selections last year? Last year's form asked hospitals to identify both 2017 and 2018 ecqm selections. A: Yes, however modifications were needed. On August 2, 2017, the Centers for Medicare & Medicaid Services (CMS) published its fiscal year (FY) 2018 Inpatient Prospective Payment System (IPPS) final rule. The rule included modifications to CY 2017 ecqm reporting requirements with a reduction from 6 to 4 ecqms required and also finalized this requirement for CY 2018 ecqm reporting. Subsequently in late August 2017, following the modifications and to remain closely aligned with CMS, The Joint Commission provided additional information and instructions to hospitals electing to reduce the number of ecqms to report from 6 to 4 for 2017 and In July 2018, The Joint Commission announced the Direct Data Submission (DDS) Platform was now available to all accredited hospitals for submission of CY 2018 ecqm data. The 2018 ecqm selection form is needed to capture in the ORYX Measure Selection (OMS) application which of the two ecqm data submission methods hospitals with ORYX ecqm requirements will use, and which ecqms. The Joint Commission makes all changes to the OMS application. In addition, hospitals new to DDS must indicate the month their organization would like to be on-boarded to the Platform (August 2018 thru February 2019). QUESTION 8: How do you know if you have already selected ecqm measures? A: A hospital s current ecqm submission method and measure selections are viewable in the ORYX Measure Selection (OMS) application, which is available on Joint Commission Connect. See the Continuous Compliance Tab and open ORYX Measure Selections to view ecqms and chartabstracted measure selections for your hospital. QUESTION 9: Once a participant selects their measures via the ecqm selection form, will these measure selections be reflected somewhere on the DDS platform? A: On the DDS Platform, there is a submit page that indicates which measures are selected. There is a delay between the updating of OMS and when those selections are seen on the DDS platform. The platform is updated approximately once a month around the time of that month s Office Hours. QUESTION 10: For 2019 ORYX requirements, are any chart abstracted outpatient (OP) measures required? A: There are no required OP measures. There are two OP measures, OP-18 and OP-23 that may be selected from the list of additional Joint Commission chart-abstracted measures available for selection. QUESTION 11: Did I hear correct that in 2020 all chart-abstracted measures will be gone? What are the Joint Commission's thoughts on the future of chart-based measures as more measures are retired? 2

3 A: No, to clarify on slide 8, it was shared that 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. We work to stay as closely aligned with the Centers for Medicare & Medicaid Services (CMS) as possible. Their proposed and final rules have been showing declining options for chart-based measures, so it seems to be headed in that direction, but it is too soon to say. In addition, chartabstracted measures continue to be utilized for certification purposes. QUESTION 12: If I remember correctly, we need to select 2019 ecqm measures by 12/31/18, although these data will not be due until Why do we have to make this selection so far in advance? A: Information and instructions regarding 2019 ORYX measure selections was shared on November 7, 2018 following this webinar and is available at: The November 7 communication specific to ecqms notes, As previously communicated, beginning CY 2019, all facilities submitting ecqms will use the Direct Data Submission Platform (DDSP). The Joint Commission will provide additional communication and instruction regarding the transition to the DDSP in spring For 2019 ORYX reporting, the ecqm requirement is a minimum of four ecqms, for a minimum of one calendar quarter. Organizations are not required to indicate their CY 2019 ecqm selections at this time, but may use this form to do so if they choose. Please note that we will not be entering ecqm selections for CY 2019 in the ORYX Measure Selection (OMS) application on Joint Commission Connect until after CY 2018 data close in spring We will provide organizations with the opportunity to make 2019 ecqm selections when the additional communication and instructions regarding the transition to DDSP is shared in spring Once a hospital has made their initial DDSP ecqm selections for the calendar year (e.g., CY 2019) for onboarding purposes, the Platform provides functionality which allows users to change which ecqms they are selecting at time of data submission. This functionality exists to allow hospitals that have implemented new/upgraded EHR software or who have identified interoperability / data mapping issues to modify their ecqm selections without having to contact The Joint Commission for assistance. QUESTION 13: For 2019 chart-abstracted reporting, if we have more than 300 deliveries per year, will we need to submit a measure selection form due to the addition of PC-06? A: Hospitals that have at least 300 live births will automatically have PC-06 added, effective with 1/1/2019 discharges. Please review the November 7 communication regarding information and instructions for 2019 ORYX measure selections carefully to determine if your organization needs to complete the 2019 ORYX Measure Selection Form, found at: 3

4 QUESTION 14: Do I still need to submit a 2018 ecqm measure selection form if we are not changing our selection from last year? A: Completion of the form is encouraged as a review and confirmation of your 2018 ecqm submission method and selection of measures. If no form is received, the current ecqm submission method and selections as they are currently shown in the OMS application will be retained. QUESTION 15: If we submitted ecqms through the Direct Data Submission (DDS) Platform last year and there are no changes for this year, do we need to resubmit the form? A: If a hospital used the Direct Data Submission Platform for its CY 2017 submission, completion of the form is encouraged as a review and confirmation of its 2018 ecqm submission method and selection of measures. If no form is received, the current ecqm submission method and selections, as they are currently shown in the OMS application, will be retained. QUESTION 16: Why were we able to use estk-8 and estk-10 last year for ecqms- and they are not available this year? I thought there were no changes in the requirements from 2017 to 2018? A: The Joint Commission retired estk-8 and estk-10 effective with 1/1/2017 discharges. The Joint Commission elected to retire estk-8 (Stroke Education) and estk-10 (Assessed for Rehabilitation) as these ecqms had become check box measures, and their value on patient safety and quality of care had been diminished. QUESTION 17: What is the difference between what's asked of CMS and The Joint Commission regarding performance measures and retired measures for 2019? A: Regarding alignment with CMS for 2019: For hospitals with ORYX ecqm reporting requirements The Joint Commission requirement is the same as CMS with hospitals 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. The Joint Commission is not retiring ED-1, IMM-2 and VTE-6 for However, these measures will no longer be required for hospitals with an ADC >10 and these hospitals required chart-abstracted measures are being reduced from 5 to 2 for reporting. QUESTION 18: Slide 14 asks the question What if my hospital cannot report on the required 2 chartabstracted measures (i.e., ED-2 and PC-01) as they are not applicable to our services provided and patient populations. How do hospitals notify you that they don't have populations for the required measures? Or, do they just not submit anything and it doesn't count against them? A: As part of the measure selection process, if a hospital does not select and then submit data for all required chart-abstracted measures, the hospital is attesting to the fact that it does not provide the related service or serve the related patient population and may be asked to verify at the time of survey. QUESTION 19: Slide 16 asks the question Is the Joint Commission retiring the three chartabstracted measures that CMS is removing effective for the CY 2019 reporting period (i.e., ED-1, 4

5 IMM-2 and VTE-6)? In the response it includes, The Joint Commission is not retiring ED-1, IMM-2 and VTE-6 for However, these measures are longer required for Hospitals with an ADC > 10. Should there be the word "no" in the sentence that starts with "However"? A: The response is correct as worded. ED-1, IMM-2 and VTE-6 will remain on the list of Additional Joint Commission Chart-Abstracted Measures Available for Selection. These measures may be selected by CAHs, small (ADC 10) and specialty hospitals to meet their ORYX requirements, or if a hospital with an ADC > 10 wishes to select additional chart-abstracted measures for reporting in CY 2019 beyond the two required chart-abstracted measures, QUESTION 20: For 2019, our ecqms will be transmitted using the direct data submission platform, but we will continue with a vendor for chart-abstracted transmission correct? A: Correct. All hospitals submitting ecqm data for CY 2019 will be transitioned to the DDS Platform beginning with CY 2019 data and forward. 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. QUESTION 21: We have >10 average daily census, but we have less than 300 deliveries per year. Are we required to submit the PC measures including PC-06 in 2019? A: Hospitals with an ADC >10 and less than 300 deliveries report on 2 required chart-abstracted measures applicable to the services provided and population served; ED-2 Admit Decision Time to ED Departure Time for Admitted Patients and PC-01 Elective Delivery. Only 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. QUESTION 22: PC-06 - is there really no sampling for PC-06? Hospitals will have to chart abstract discharge disposition for every delivery. What is the rationale for not allowing sampling for the new measure PC-06? A: Correct, this measure is not eligible for sampling, and hospitals are encouraged to utilize data sources that reduce medical record review e.g., using vital records, delivery logs or clinical information systems. This measure is almost entirely code driven, and there are several quality collaborative organizations that currently use the measure and they do not chart abstract the data elements, rather they are using discharge data and vital records or birth certificate data. To minimize data collection burden, we are encouraging hospitals and vendors to take this approach. The PC data elements Birth Weight and Term Newborn already include the following note for abstraction encouraging the use of administrative data: It is acceptable to use data derived from vital records reports received from state or local departments of public health, delivery logs or clinical information systems if they are available and are directly derived from the medical record with a process in place to confirm their accuracy. If this is the case, these may be used in lieu of the acceptable data sources listed below. A similar note has been added to Discharge Disposition in the addendum posted in November, to clarify that for PC measures administrative data sources are acceptable. 5

6 QUESTION 23: For high volume hospitals, the specification reads that hospitals will be burdened with hundreds of reviews on PC-06? A: See Question 22 for response. QUESTION 24: Multiple questions have been asked re: PC 06. Will there be an educational opportunity on it? A: On November 12 a webinar was held for ORYX vendors and one of the topics covered was PC-06, as ORYX vendors have primary responsibility to educate their hospital clients. We are sharing a link to the webinar slides that address PC-06 for your information. QUESTION 25: What about the rest of the PC measures, will they remain as 'sampling' or will it be 100% as question asked above re: PC-06, where disposition for all deliveries might be required? A: There is no change to the sampling for the other PC measures. PC-04 does not allow sampling, for PC-01, 02, 03, 05 sampling is an option. QUESTION 26: If the screening portion of Tobacco and Alcohol are retired, how are we to address Practical Counselling, Brief Intervention, Outpatient Referrals, and Outpatient treatment without the treatment being assigned for every patient? A: The data element Tobacco Use Status has always been required for all of the TOB measures. TOB- 1 is being retired, but tobacco use screening is still required for the TOB-2 and TOB-3 measures. QUESTION 27: Did you say that the direct data submission platform for reporting 2018 ecqms opened in July? A: Yes. If you selected DDS as your submission option, it is open and available for 2018 submissions. Since August we have been on-boarding new organizations in monthly groups. If you have not completed the 2018 ecqm selection form and would like to choose the Direct Data Submission Platform for submitting your CY 2018 ecqm data, please contact HOORYX@jointcommission.org. QUESTION 28: If we choose to be a DDS submitter, when is the first date that we can begin testing? Do you provide a testing environment before the final submission? A: The DDS Platform does not utilize the concept of separate Production and Trial data upload. Rather, when a hospital uploads their data onto the DDS Platform, the data are loaded into their individual workspace. Hospital staff can then use additional portions of the DDS Platform to evaluate the completeness and accuracy of their data. Once a hospital is satisfied that the data within their workspace is ready to be submitted as Production data to The Joint Commission, the hospital will utilize functionality within the DDS Platform to submit their data QUESTION 29: Is using the cloud version for data submission mandatory at this point or can we continue to use our vendor for data submission? A: For 2018 ecqm submission, a hospital may use an ORYX ecqm vendor or the Direct Data Submission Platform. For 2019 ecqm data, all organizations will be transitioned to the DDS Platform. Hospital staff using the Joint Commission s DDS Platform can grant external user permissions (e.g., vendor or consultant) to assist with functionality such as uploading QRDA I documents or the data 6

7 verification process (e.g., correct QRDA I generation based on error/warnings, review measure results and rates to assist with data mapping issues). QUESTION 30: Department of Defense (DoD) Facilities: Do you have any word on how we will transition to the DDS? Will we be entered the same way as civilian facilities? A: We are working with the DoD to make the transition as smooth as possible. There will be additional calls to work with the DoD to plan for the transition. QUESTION 31: If I am a hospital, can I utilize an ORYX approved vendor to do my complete ecqm submissions or am I am compelled to use a vendor to do my activities...will I get any bumper to bumper guidance from ORYX to complete a successful ecqm submission? A: For 2018 ecqm submission, a hospital may use an ORYX ecqm vendor or the Direct Data Submission Platform. For 2019 ecqm data, all organizations will be transitioned to the DDS Platform. Hospital staff using the Joint Commission s DDS Platform can grant external user permissions (e.g., vendor or consultant) 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). To transition hospitals to the platform and offer submission support: During the onboarding process, hospitals electing to use the CY 2018 DDS Platform, will be provided with access to a series of self-directed webinars. In addition, the DDS Platform contains help documentation and the ability to ask questions. The Joint Commission conducts monthly DDS "Office Hours". Content includes tips for successful use of the DDS Platform and frequently asked questions. The webinars are staffed by The Joint Commission and Apervita staff to answer questions for hospitals. QUESTION 32: What is the rationale for excluding vendor submissions for ecqms? A: The Direct Data Submission Platform was implemented in response to accredited organizations requesting a cost-effective method for submittal of ecqm data, as well as a way to use the same files submitted to CMS. Keep in mind, hospital staff using the Joint Commission DDS Platform have the ability to grant external user permissions to assist with the upload process 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 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. QUESTION 33: I am not sure my EMR will be compatible with the DDS-- is there a way to confirm this before making a switch from chart-abstracted measures to ecqms? A: The DDS Platform has been implemented such that it will accept the same QRDA-I Documents that are submitted to CMS. To submit ecqm data to The Joint Commission, your organization will need to have an EHR/EMR or other health information technology system in place that can generate the correct version of the 7

8 QRDA-I Documents for the calendar year data being submitted. It is up to the hospital how they generate these documents. For more information concerning the submission standards being used to generate the QRDA-I Documents, please visit CMS/ONC s ecqi Resource Center at Go to Tools and Resources in the main menu and then the ecqm Standards and Tools Version tab. In addition, please see the following link ( and use the table of contents to navigate to the section Attachment A CY 2018 and CY 2019 ecqm Versions, HL7 Standards, and CMS Implementation Guides for specific ecqm versions, HL7 standards, and guides that must be used for CY 2018 and CY 2019 reporting. QUESTION 34: Can you explain "onboarding" and the steps needed? A: Information about the DDS Platform and onboarding was presented during a previous Pioneers in Quality webinar. See the July 24th 2018 Pioneers in Quality TM webinar Joint Commission 2018 ecqm Direct Data Submission Platform: Your Questions Answered available at _answered_/. As hospitals are being on boarded to the CY 2018 DDS Platform, their Designated Contact for the Platform will receive an that documents the steps required to initially access the Platform. Additionally, during the onboarding process, hospitals will be provided with access to a series of selfdirected webinars. Once on boarded, hospitals have access to the DDS Platform s help documentation and are provided functionality to ask questions. The Joint Commission conducts monthly DDS "Office Hours". Content includes tips for successful use of the DD Platform and frequently asked questions. The webinars are staffed by The Joint Commission and Apervita staff to answer questions for hospitals. QUESTION 35: How do we get information about the DDS process for CY 2018 data submission? How do we get on boarded? A: Please see above response for Question 34. Additionally, if you have not completed the 2018 ecqm selection form and would like to choose the Direct Data Submission Platform for submitting your CY 2018 ecqm data, please contact HOORYX@jointcommission.org. QUESTION 36: I am accountable for 25 acute care hospitals will I be able to submit their ecqms for them through the DDS? A: Designated DDS Contacts with responsibility for multiple hospitals (i.e., a Super User) will utilize the same login/password to onboard all hospitals. Super Users are able to switch within the Platform between hospitals to perform other activities without having to logout. Additional guidance is available for the role of Super Users on the DDS platform within the What you need to know: Frequently Asked Questions (FAQs) 2019 ORYX Performance Measure Reporting Requirements document (within Question 2.b.1.16) available on the Joint Commission website at: UPDATED.pdf. QUESTION 37: Is there dedicated DDS support, if so, what is the turnaround time? 8

9 A: Yes, there is dedicated support. Turnaround time depends on the issue encountered. In terms of file turnaround, most hospitals can upload and process measures and submit without issue. We have seen organizations do all steps within a matter of hours. The processing time depends on file volume. Platform service ticket tracking is monitored during business hours from 9-5 central time. QUESTION 38: Where can I find benchmarks for the ecqms we submitted last year, 2017 performance? A: ORYX ecqm Feedback Reports are provided annually to hospitals that submitted ecqm data to The Joint Commission. The report reflects data submitted for the respective ecqm reporting year. The 2017 ORYX ecqm Feedback Reports will be available late 2018/early QUESTION 39: Will CY 2019 ecqms results be publicly reported? A: At this time, ecqm data is not being publicly reported by The Joint Commission on Quality Check or used in accreditation activities. QUESTION 40: What is the rationale behind requiring chart-abstracted measures when there are ecqm equivalents? A: For 2019, there are only three chart-abstracted measures with ecqm equivalents ED-2, PC-01 and PC-05. QUESTION 41: You stated 2018 ecqms will be received in Can you clarify that we are able to submit 2018 ecqms any time now through the end of Feb. 2019? A: The deadline for submission of CY 2018 ecqms to The Joint Commission is March 15, Once on boarded, hospitals may upload their QRDA-I Documents, verify their data, and submit any time prior to the submission deadline. QUESTION 42: Should we wait until Jan to submit our 2018 ecqms to avoid a transaction fee? A: No, Any data due after January 2019 will be covered by the annual fee. For 2019, the annual fee will include 2018 ecqm data which is due to The Joint Commission by March 15, 2019 and chartabstracted data for 3 rd and 4 th quarter 2018 and 1 st and 2 nd quarter 2019, which are due January 31, April 30, July 31 and October 31, 2019, respectively. QUESTION 43: When do you expect to post the billing scale for ecqm? It s very important for those looking to budget for A: Beginning in January 2019, HCOs with ORYX requirements will be directly billed an annual rate based upon organizational weighted volumes for both ecqms and chart-based submissions. The weighted volume is based on inpatient discharges and outpatient visits, such as used in the hospital accreditation program. Performance measurement (ORYX) annual fees will be billed on a separate line of the January, annual fee invoice. QUESTION 44: How much difference will there be between fees charged to vendor versus annual fee to hospital? A: As the annual fee is based on organization weighted volumes for both ecqms and chart-based submissions, the fee will vary. Prior to making the decision and implementing the ORYX annual fee beginning January 1, 2019 market research was conducted to obtain the voice of the customer. Through the market research we determined that some organizations were paying a 9

10 considerable amount for ecqm submission, and this was coupled with chart-abstracted transmission fees. QUESTION 45: What additional information is available regarding 2019 billing? A: The fee and related explanation about the fee will be on the January invoice posted to the HCO extranet. The invoice is accessible on the HCO Extranet under the Survey Process Tab and then within the Contracts and Billing Column. For more specific questions about the invoice process, there is an FAQ specific to billing and invoices offered in the same section of the HCO extranet. QUESTION 46: If we are already paying a vendor fee for CMS submission, why is the Joint Commission charging again? A: To date the contractual relationship with ORYX vendors has been between the vendor and The Joint Commission, including transmission fees. To address and simply the billing structure for ORYX reporting requirements we are moving to an annual rate directly billed to the hospital. QUESTION 47: Can you give an idea of the quarterly or yearly new charges hospitals will see. For example a hospital with medium volume and X amount of measures will see charges around X? We do not know what was charged and vendor did not pass on to us. A: See responses to Questions 43 and 45 Certification QUESTION 48: Hospitals that are PSC, will they be automatically turned on for CSTK-01 and STK-OP- 1 effective 1/1/19? A: Yes. These measures will be automatically started on 1/1/2019. QUESTION 49: We are using Premier to submit our Chart Abstracted Measures for Stroke. Do we also have to enter them manually via the CMIP? A: If you are submitting your certification data through a vendor, the data cannot be manually entered into CMIP. 10