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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 and Chart-abstracted measures are submitted for all four (4) quarters unless otherwise noted.
HAP Small Acute Care Hospitals are not required to submit PC measures but may do so if they choose if obstetrical services are provided.
In order to meet ORYX requirements, submitted measures must be applicable to patient population/services offered.
[HAP Small] Hospitals with <26 Licensed beds AND < 50,000 Outpatient visits |
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REQUIRED: Submit any three (3) measures (chart-abstracted measures and/or eCQMs) applicable to patient population/ services offered.
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AVAILABLE eCQMs: |
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 |
eHH-01(eCQM): Hospital Harm—Severe Hypoglycemia Measure |
eHH-02 (eCQM): Hospital Harm—Severe Hyperglycemia Measure |
eOP-40 (eCQM): ST-Segment Elevation Myocardial Infarction |
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-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 |
PC-01 (CAM): Elective Delivery |
PC-02 (CAM): Cesarean Birth |
PC-06 (CAM): Exclusive Human Milk Feeding |
PC-06 (CAM): Unexpected Complications in Term Newborns |
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 |