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• 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 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 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.

  Due to the discontinuation of the DDSP hosted by Apervita as a result of that company’s closure, CY2021, CY2022, CY2023 ORYX performance measurement deadlines were delayed; a new Joint Commission DDSP became available the second half of CY2022. Hospitals submitted CY2021, CY2022, CY2023 on a modified timeline. CY2024 data submission is expected to return to a “normal” schedule

  • 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.

The Annual 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)

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

Information on resubmission is pending. 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