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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-0605 (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 |
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