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CY2022 ORYX Requirements for [HAP Large] Acute Care Hospitals with Obstetrical Services |
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How are [HAP Large] Acute Care Hospitals defined as it relates to ORYX Requirements?
For The Joint Commission, ORYX performance measurement requirements are specifically applicable to organizations accredited under the Hospital Accreditation Program (HAP).
HAP Large are defined as ≥26 Licensed beds OR ≥ 50,000 Outpatient visits
Refer to your Joint Commission Connect Site eAPP Hospital Volume or view the DDSP HCO Characteristics Organization Requirements tab for licensed bed / outpatient volume information.
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eCQMs are submitted for three (3) quarters.
Chart-abstracted measures are submitted for four (4) quarters. unless otherwise noted.
In order to meet ORYX requirements, submitted measures must be applicable to patient population/services offered.
[HAP Large] Hospitals with ≥ 26 Licensed beds OR ≥ 50,000 Outpatient visits AND Provide Obstetrical Services |
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REQUIRED MEASURES: The following perinatal care measures is required if an organization has between 1-299 live births annually. NOTE: PC measures may be submitted as either Chart-abstracted Measure or eCQM; if submitted as eCQM, it counts towards the eCQM minimum requirement. |
ePC-01 or PC-01 (eCQM or chart-abstracted): Elective Delivery |
REQUIRED MEASURES: The following four perinatal care measures are required if an organization has 300 or more live births annually. NOTE: PC measures may be submitted as either Chart-abstracted Measure or eCQM; if submitted as eCQM, it counts towards the eCQM minimum requirement. |
ePC-01 or PC-01 (eCQM or chart-abstracted): Elective Delivery |
ePC-02 or PC-02 (eCQM or chart-abstracted): Cesarean Birth |
ePC-05 or PC-05 (eCQM or chart-abstracted): Exclusive Human Milk Feeding |
ePC-06 or PC-06 (eCQM or chart-abstracted): Unexpected Complications in Term Newborns |
AVAILABLE: Your hospital must submit a minimum of four(4) eCQMs from those listed below: |
eED-2 (eCQM) Admit Decision Time to ED Departure-Admit |
eOPI-1 (eCQM) Safe Use of Opioids |
ePC-01 (eCQM) Elective Delivery |
ePC-02(eCQM): Cesarean Birth |
ePC-05 (eCQM) Exclusive Breast Milk Feeding |
ePC-06 (eCQM) Unexpected Complications in Term Newborns |
ePC-07 (eCQM) Severe Obstetric Complications |
eSTK-2 (eCQM) Discharged on Antithrombotic Therapy |
eSTK-3 (eCQM) Anticoagulation Therapy Atrial Fibrillation/Flutter |
eSTK-5 (eCQM) Antithrombotic Therapy by End of Hospital Day 2 |
eSTK-6 (eCQM) Discharged on Statin Medication |
eVTE-1 (eCQM) Venous Thromboembolism Prophylaxis |
eVTE-2 (eCQM) ICU Venous Thromboembolism Prophylaxis |
OPTIONAL Chart-Abstracted Measures |
ED-1 (CAM) Median ED Arrival to ED Departure-Admit |
ED-2 (CAM) Admit Decision Time to ED Departure-Admit |
HBIPS-1 (CAM) Admission Screening |
HBIPS-2 (CAM) Hours of Physical Restraint Use |
HBIPS-3 (CAM) Hours of Seclusion Use |
HBIPS-5 (CAM) Antipsychotic Medications at Discharge |
IMM-2 (CAM) Influenza Immunization NOTE: IMM-2 is a seasonal measure; only 1Q and 4Q data are submitted |
OP-18 (CAM) Median ED Arrival-ED Departure at Discharge |
OP-23 (CAM) Head CT or MRI Scan Results-Stroke |
SUB-2 (CAM) Alcohol Use Brief Intervention |
SUB-3 (CAM) Alcohol & Drug Use Treatment at Discharge |
TOB-2 (CAM) Tobacco Use Treatment |
TOB-3 (CAM) Tobacco Use Treatment at Discharge |
VTE-6 (CAM) Hospital Acquired Potentially-Preventable VTE |