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

The 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/measurement/reporting/accreditation-oryx/

The Joint Commission Guide for Data Entry of Chart-Abstracted Measures which describes the aggregate data requirements for 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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title1.3: Have any measures been retired or added for 2023 ORYX reporting requirements?

Retired: The Joint Commission retired chart-abstracted HBIPS-1 for CY2023 effective 1/1/2023 patient discharges.

Added: The following eCQM only measures were added for CY2023 effective 1/1/2023 patient discharges:

eHH-01 Hospital Harm—Severe Hypoglycemia Measure
eHH-02 Hospital Harm—Severe Hyperglycemia Measure
eOP-40 ST-Segment Elevation Myocardial Infarction (STEMI)

CMS is the steward for these measures and the specifications are available on the eCQI Resource Center. There are no corresponding chart abstracted measures. These measures are not required for 2023 collection but are offered as an optional measures to meet ORYX eCQM requirements.

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title1.4: What measures are available for reporting in CY2023?

The CY2023 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/oryx/2023-oryx-reporting_requirements.pdf

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

Please see the “ORYX Performance Measurement Timeline” documentation for key dates and information.

https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/71008257/ORYX+Performance+Measurement+Timeline

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title1.8: Can we resubmit data?

Information on resubmission is pending.

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Continue to the next section: General ORYX Information - Basics

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