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title1.1: What changes have been implemented regarding ORYX requirements / Accreditation data submission for CY2023?

  • Starting with CY2023, hospitals required or electing to submit eCQMs must submit all four (4) quarters of data to The Joint Commission. This is a change / increase from CY2022 reporting of three (3) quarters.

  • Hospitals who are required but unable to submit eCQMs and have requested and been granted an extenuating circumstance from The Joint Commission, will be required to instead submit a minimum of three chart-abstracted measures for the full CY2023 calendar year.

    • In no case may an eligible Hospital or Critical Access Hospital be granted an extenuating circumstance exception for more than five consecutive years.  This is in alignment with CMS

. The “ePC-07 Severe Obstetric Complications” measure was added as a new Joint Commission only eCQM. There is no corresponding chart abstracted PC-07 measure. This measure is not required for 2022 collection but is offered as an optional measure to meet ORYX eCQM requirements

    • .

  • Due to the discontinuation of the DDSP hosted by Apervita as a result of that company’s closure, CY2021

and

  • , CY2022, CY2023 ORYX performance measurement deadlines were delayed; a new Joint Commission DDSP became available the second half of CY2022. Hospitals submitted CY2021

and

  • , CY2022, CY2023 on a

delayed and abbreviated

  • modified timeline.

CY2023

  • CY2024 data submission is expected to return to a “normal” schedule.

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title1.2: What are the 2023 ORYX Performance Measurement Reporting Requirements for this year?

The CY2023 Annual reporting requirements and list of available measures are available on our the Measurement > Reporting part of our external website or copy and paste the following web address in your internet browser: https://www.jointcommission.org/-/media/tjc/documents/measurement/oryxreporting/2023accreditation-oryx-reporting_requirements.pdf/

The Joint Commission Guide for Data Entry of Chart-Abstracted Measures which describes the aggregate data requirements for hospitals organizations submitting chart-abstracted measure data is available on the Measurement>Specifications part of our external website, or copy and paste the following web address in your internet browser: https://www.jointcommission.org/measurement/specification-manuals/chart-abstracted-measures/

As a reminder, effective CY2021, for the Hospital Accreditation Program (HAP) and Critical Access Hospital Accreditation Program (CAH), ORYX Performance Measurement Reporting requirements include the following:

ORYX eCQM and/or Chart-Abstracted data submission:
•Acute Care Hospitals are defined as having Licensed Beds >= 26 OR Outpatient Visits >= 50,000, and are no longer defined by ADC >10

•Freestanding Psychiatric Facility reporting requirements are not defined by Licensed Beds / Outpatient Visits and are required to submit chart-abstracted HBIPS measures

•Small Hospitals are defined as having Licensed Beds <26 AND Outpatient Visits < 50,000, and are no longer defined by ADC <= 10; Small Hospitals cannot self-report. (Refer to question 5.1 in “Measure Requirements: By Hospital Type” regarding self-reporting)

•Critical Access Hospital (CAH) Accreditation Program reporting requirements are not defined by Licensed Beds / Outpatient Visits and are required to submit chart-abstracted measures and/or eCQMs; CAHs cannot self-report. Refer to question 5.1 in “Measure Requirements: By Hospital Type” regarding self-reporting)

•The Specialty Hospital designation was removed effective CY2021; all hospitals previously designated as "Specialty" for ORYX reporting purposes were placed in the appropriate ORYX policy based upon Licensed Beds and/or Outpatient Visits. Refer to question 5.5 in “Measure Requirements: By Hospital Type” regarding self-reporting)

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title1.6: Can we self-report our data/make the data available at the time of survey?

No; Effective 1/1/2021 patient discharges, we removed the option of self-reporting data. All hospitals organizations must submit eCQM and/or chart-abstracted data to The Joint Commission via the Direct Data Submission Platform (DDSP). Hospitals that previously self-reported in the past data are required to submit their data via the DDSP.

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title1.7: When can we begin entering or uploading CY2023 data?

Please see the “Timeline” documentation under “Measurement”, “Resources” on our website “ORYX Performance Measurement Timeline” documentation for key dates and information. The DDSP for CY2023 is expected to open in July 2023.

https://wwwjointcommission-ddsp.jointcommission.org/measurement/resourcesatlassian.net/wiki/spaces/DCS/pages/71008257/

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title1.8: Can we resubmit 1Q2021 or 2Q2021 data?

Information on resubmission is pending.

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Continue to the next section: General ORYX Information - Basics

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