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NEW for 2024:

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titleAPPLICABLE TO ALL JOINT COMMISSION ACCREDITED HOSPITALS WITH ORYX REQUIREMENTS:

  • Effective January 1, 2024, The Joint Commission is implementing a new decision rule for hospitals and critical access hospitals to reinforce the requirement to participate in the ORYX® performance measurement initiative. Organizations may receive a Denial of Accreditation if they fail to meet ORYX performance measure reporting requirements for two consecutive years in the absence of receipt of an approved extenuating circumstance request from The Joint Commission. Refer to Key Communications for additional information.

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titleAPPLICABLE TO ACUTE CARE HOSPITALS (HAP Large AND HAP Small):

  • Effective July 1, 2024, acute care hospitals who are required through a CMS program to participate in NHSN will be required to join The Joint Commission NHSN Group. The Group will give Joint Commission access to the following measures with no patient identifiers: CAUTI, CLABSI, CDI, MRSA Bacteremia, SSI: Colon, SSI: Hyst.

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titleAPPLICABLE TO LARGE ACUTE CARE HOSPITALS:

If required but unable to submit any eCQMs for CY 2024, HCOs must submit an extenuating circumstance request (ECR) and receive an exemption from The Joint Commission. HCOs will be required to submit three (3) chart-abstracted measures for all four (4) quarters of CY2024.

See also: Extenuating Circumstances

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titleAPPLICABLE TO LARGE ACUTE CARE HOSPITALS WITH OBSTETRICAL SERVICES:

  • Effective CY2024, the PC requirements for “Large” facilities are no longer based on annual live birth volume; PC requirements apply to all “Large” HAP facilities that provide obstetrical services.

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titleAPPLICABLE TO FREE-STANDING PSYCHIATRIC HOSPITALS:

  • Separately accredited Free-standing Psychiatric Hospitals are required to submit HBIPS-2, HBIPS-3, plus one additional measure from the measure list.

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titleAPPLICABLE TO ASSISTED LIVING COMMUNITIES:

  • Effective 1/1/2024, ALCs are required to participate in the ORYX Performance Measurement and submit data to The Joint Commission via the DDSP.

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titleNEW MEASURES for CY2024:
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titleRETIRED MEASURES effective 12/31/2023 and no longer available for CY2024:

  • eCQM: Admit Decision Time to ED Departure Time for Admitted Patients (eED-2) 

  • eCQM: Discharged on Statin Medication (eSTK-6) [Note: the chart-abstracted STK-6 measure remains required for applicable Stroke certification programs]

  • CAM: Hospital-Based Inpatient Psychiatric Services - Multiple Antipsychotic Medications at Discharge with Appropriate Justification (HBIPS-5)  

  • CAM: Tobacco Treatment Measures - Tobacco Use Treatment Provided or Offered (TOB-2) and Tobacco Use Treatment (TOB-2a)

Refer to the Timeline for information regarding data submission deadlines: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/71008257

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ORYX REQUIREMENTS for 2024:

[HAP Large] Acute Care Hospitals that Provide Obstetrical Services
HAP Large are defined as ≥26 Licensed beds OR ≥ 50,000 Outpatient visits

[HAP Large] Acute Care Hospitals that DO NOT provide Obstetrical Services
HAP Large are defined as ≥26 Licensed beds OR ≥ 50,000 Outpatient visits

[HAP Small] Acute Care Hospitals
HAP Small are defined as <26 Licensed beds AND <50,000 Outpatient visits

[CAH] Critical Access Hospitals
[CAH] Critical Access Hospitals adhere to the CAH standards manual, and are a specific designation by the state as a critical access hospital in a rural area.

[HAP PSYCH] Freestanding Psychiatric Hospital
HAP PSYCH are defined as a "Freestanding" Psychiatric Facility licensed and separately accredited as freestanding psychiatric hospital; it is not a unit within a hospital that is surveyed at the same time as the hospitals and shares an HCO ID #.

[ALC] Assisted Living Community
ALCs adhere to the ALC standards manual.

Suspended Accreditation Programs
Suspended organizations may submit ORYX Performance Measures to The Joint Commission via the DDSP if they choose.