Updating ORYX® Measure Set Selections and Reporting Options for 2016

As noted in the October 2015 Perspectives, hospitals and critical access hospitals accredited by The Joint Commis- sion will continue to have flexibility in meeting ORYX® performance measure reporting requirements for calendar year 2016. Measure reporting requirements can be met through the submission of data on six measure sets for hospitals (four sets for critical access hospitals) by selecting chart-abstracted measures, electronic clinical quality measures (eCQMs), or a combination of these. Table 1 below displays the three avail- able reporting options.

Table 1. 2016 Flexible ORYX Performance Measure Reporting Options

Option 1: Vendor submission of quarterly data on six of nine sets of chart-abstracted measures

Option 2: Vendor submission of data on six of eight sets of eCQMs

Option 3: Vendor submission of data on six measure sets using a combination of chart-abstracted measures and eCQMs

Options and Due Dates

On October 28, 2015, The Joint Commission’s Division of Accreditation and Certification Operations sent a direct com- munication to accredited hospitals with instructions and due dates for submitting ORYX measure set selections for 2016.

The first due date, November 30, 2015, applies to hospitals currently reporting on six sets of measures (four sets for critical access hospitals) for 2015 that are not required to add measure sets for 2016 and that are not electing to make any changes to their 2015 measure set selections or vendor for reporting in 2016. This date also applies to hospitals that are electing to report on a minimum of six sets of chart-abstracted measures (Option 1).

The second due date, January 31, 2016, applies to hospi- tals that are exploring vendor submission of data for the third and/or fourth quarter of 2016 on a minimum of six sets of eCQMs (Option 2) and hospitals that are considering vendor submission on a minimum of six sets of measures using a combination of chart-abstracted measure sets (monthly data submitted on a quarterly basis) and eCQM sets (third and/or fourth quarter 2016) (Option 3).

Reporting eCQMs

Hospitals choosing Option 2 or Option 3 that are unable to report on all eCQM measures that comprise the eCQM

set may now report on as few as one measure in an eCQM set—and the set will count toward meeting the six-set report- ing requirement. Vendors will be invoiced for each individual eCQM measure set submitted.

Hospitals that choose Option 3 may report on both the chart-abstracted and eCQM version of the same measure set. Each version will count as an individual set of measures toward meeting the six-measure-set reporting requirement—

that is, each version of the same measure set will be billed as a separate measure set.

These modifications provide closer alignment with Centers for Medicare & Medicaid Services (CMS) and sup- port accredited organizations in their efforts to meet CMS eCQM reporting requirements for calendar year 2016. At the same time, they encourage selecting and reporting on the same eCQMs to The Joint Commission.

Please note that, for hospitals choosing Option 2 or Option 3, The Joint Commission will not publicly report the 2016 eCQM data on Quality Check®.

ORYX Measure Changes for 2016

CMS has made multiple changes in its Hospital Inpatient Quality Reporting Program, and The Joint Commission has made changes to continue to align as closely as possible with CMS. Table 2, on page 10, shows Joint Commission measure sets effective January 1, 2016, that can be used to meet 2016 ORYX reporting requirements for accreditation purposes.

While reviewing Table 2 and making selections, hos- pitals should remember that measure set selections must be relevant to the services provided by the organization and the patient populations served. After determining measure set selections, hospitals should access the “2016 Flexible ORYX Reporting Options Measure Set Selection Instruc- tions and Forms” available at http://www.jointcommission

.org/assets/1/18/2016_Measure_Set_Selection_Instx- Forms_10-28-2015.pdf to proceed with submitting their selections.

Using the Stroke Measure Set to Meet Requirements for Accreditation and/or Certification

As shown in Table 2, the chart-abstracted stroke (STK) measure set now has only a single measure—STK-4: Throm- bolytic Therapy—remaining for 2016 accreditation purposes. A Joint Commission–accredited hospital that is (or is seeking to become) Primary or Comprehensive Stroke Center certi-

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Updating ORYX® Measure Set Selections and Reporting Options for 2016 (continued)

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fied can select and report on the single chart-abstracted STK-4 measure as one of its six sets of measures or select to report

on the stroke eCQMs for 2016 for accreditation purposes. However, those hospitals will still be required to report on all eight of the chart-abstracted STK measures for purposes of certification.

In addition, organizations that are (or are seeking to become) Joint Commission certified as a Comprehensive Stroke Center must also report data on all Joint Commission chart-abstracted Comprehensive Stroke (CSTK) measures.

Data may continue to be manually entered into the Cer- tification Measure Information Process (CMIP) application accessed through the hospital’s Joint Commission Connect™

extranet site, or the data may be reported through a Joint Commission–listed vendor that supports submission of the related measure data for purposes of certification. Compre- hensive Stroke Centers, in particular, are encouraged to report their STK and CSTK data through a Joint Commission–listed vendor.

Questions may be directed to Frank Zibrat, associate director, Accreditation Systems Integration and ORYX, at 630-792-5992 or via e-mail at fzibrat@jointcommission.org. Alternatively, questions may be submitted to HCOOryx@ jointcommission.org. P

Table 2. Joint Commission Measure Sets Effective January 1, 2016