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Topics Covered in this section:

  • Changes to CY2022 CY2024 Reporting

  • Modifications to CY2021 Reporting timeline

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Starting with CY2022, hospitals required or electing to submit eCQMs must submit a minimum of three (3) quarters of data to The Joint Commission. This is a change / increase from CY2021 reporting of two (2) quarters.

Hospitals who are required but unable to submit eCQMs and have requested and been granted
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title1.1: What policy changes have been implemented regarding ORYX requirements / Accreditation data submission for CY2022?
CY2024?

  • 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.

    • i.e. we no longer stratify OB requirements based on 1-299 or 300+ live births annually.

  • Effective January 1, 2024, The Joint Commission implemented 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.

    • Note: This is not retroactive to years prior to 2024; if an organization has ORYX requirements but does not submit required ORYX data via the DDSP, nor requests and receive an extenuating circumstance from The Joint Commission,

will be required to instead submit a minimum of three chart-abstracted measures for the full CY2022 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 ORYX performance measurement deadlines will be delayed; a new Joint Commission DDSP is available the second half of CY2022. Hospitals will be able to submit past 2Q2021, 3Q2021, 4Q2021 and/or eCQM ORYX data and begin CY2022 data submission based on the published timeline

    • and is non-responsive to our reminders to submit data or an ECR for two consecutive years (e.g. 2024 and 2025) they could receive a denial of accreditation for non-compliance.

  • Applicable to CY2024 ORYX Requirements and 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. Information on the process to join The Joint Commission NSHN group will be distributed during 2024.

    • Note: Critical Access Hospitals may participate if they choose.

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)

The CY2022
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title1.2: What are the 2022 ORYX Performance Measurement Reporting Requirements ?
for 2024?

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/-/media/tjc/documents/measurement/oryxreporting/2022-oryx-reporting-requirements--october-19-2021.pdfThe Joint Commission Guide for Data Entry of Chart-Abstracted Measures which describes the aggregate data requirements for hospitals 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/ accreditation-oryx/

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title1.3: Have any measures been retired or added for 2022 2024 ORYX reporting requirements?

Retired: Neither the Joint Commission nor CMS has retired or removed any chart-abstracted or eCQM measures for CY2022.Added: The “ePC-07 Severe Obstetric Complications” measure was added as a new Joint Commission only eCQM (Specifications available on the Measurement>Specifications part of our external website). 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 Effective 1/1/2024 patient discharges and applicable to CY2024 ORYX Requirements, The Joint Commission retired:

  • Chart-abstracted measures:

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

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

  • eCQMs:

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

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

Added:Effective 1/1/2024 patient discharges and applicable to CY2024 ORYX Requirements, The Joint Commission added:

  • Chart-abstracted measures:

    • Screening for Social Drivers of Health (SDOH-1)

    • Screen Positive Rate for Social Drivers of Health (SDOH-2)

  • eCQMs:

    • Hospital-Harm—Opioid Related Adverse Events eCQM (HH-ORAE)

    • Global Malnutrition Composite Score eCQM (GMCS)

CMS is the steward for these measures and the specifications are available on the eCQI Resource Center. These measures are not required for 2024 collection but are offered as an optional measures to meet ORYX requirements.

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title1.4: What measures are available for reporting in CY2022CY2024?

The CY2022 CY2024 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/2022accreditation-oryx-reporting-requirements--october-19-2021.pdf/

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title1.5: What is included in "outpatient visits"?

Per the description in your Joint Commission Connect eApp/General Application under Hospital site information > “Volume”, outpatient visits: Includes all clinics, outpatient surgery, physical therapy, radiology. Excludes all Laboratory tests.

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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 with ORYX requirements 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.

No – the new DDSP will not be available by 3/15/2022. Hospitals will submit their remaining CY2021 and CY2022 data to the new DDSP during the second half of 2022 and first quarter of 2023.
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title1.7: Will the new Joint Commission DDSP platform be built out and ready for submissions by 3/15/2022 – the CY2021 eCQM submission deadline?
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: Do Can we need to resubmit 1Q2021 and 2Q2021 chart-abstracted data?

Hospitals may not resubmit 1Q data, as that data was received. Organizations will have the opportunity to review / edit / enter 2Q2021 chart-abstracted data.Effective CY2023 data, chart-abstracted measures can be resubmitted if an organization identifies errors in previously entered data. For more information on resubmission, see the Resubmission help topic: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/141295632

The ORYX requirements remain the same, only the data submission is delayed. Hospitals must continue to collect, aggregate and trend their ORYX measurement data for performance improvement and accreditation survey activities.  Hospitals will submit their remaining CY2021 and CY2022 data to the new DDSP during the second half of 2022 and first quarter of 2023.
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title1.9: Should we not be doing chart abstractions for the 3rd quarter at this time due to the platform not being available?

Organizations using chart-abstracted measures to meet their ORYX requirements must submit remaining 2Q2021, 3Q2021, and 4Q2021 data. ORYX performance measurement requirements have not been suspended. Organizations should continue ORYX performance measurement efforts and be prepared to provide data if surveyed in the interim. Hospitals will submit their remaining CY2021 and CY2022 data to the new DDSP during the second half of 2022 and first quarter of 2023.

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title1.10: With the retirement of the Apervita platform we would like to understand our reporting requirements for CY2021.
How are organizations defined/categorized as it relates to determining ORYX Requirments?

•(Large) Acute Care Hospitals are defined as having Licensed Beds >= 26 OR Outpatient Visits >= 50,000

•(Small) Acute Care Hospitals are defined as having Licensed Beds <26 AND Outpatient Visits < 50,000

•Critical Access Hospital (CAH) Accreditation Program reporting requirements are not defined by Licensed Beds / Outpatient Visits, and are not required to submit perinatal care measures regardless of if they have an obstetrical unit - but may do so if they choose

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

•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 the annual reporting requirements and list of available measures applicable to each setting/service on 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/

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Continue to the next section: General ORYX Information - Basics

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