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Topics Covered in this section:

  • Changes to CY2023 ReportingCY2024 Reporting timeline

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title1.1: What policy changes have been implemented regarding ORYX requirements / Accreditation data submission for CY2023CY2024?

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.

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 were delayed; a new Joint Commission DDSP became available the second half of CY2022. Hospitals submitted CY2021 and CY2022 on a delayed and abbreviated timeline. CY2023 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.

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title1.2: What are the 2023 ORYX Performance Measurement Reporting Requirements for 2024?

The CY2023 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/2023accreditation-oryx-reporting_requirements.pdf

The 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/

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)

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title1.3: Have any measures been retired or added for 2023 ORYX reporting requirements?

Retired: The Joint Commission retired chart-abstracted HBIPS-1 for CY2023 effective 1/1/2023 patient discharges.

Added: The following eCQM only measures were added for CY2023 effective 1/1/2023 patient discharges:

eHH-01 Hospital Harm—Severe Hypoglycemia Measure
eHH-02 Hospital Harm—Severe Hyperglycemia Measure
eOP-40 ST-Segment Elevation Myocardial Infarction (STEMI/

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

Retired: 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. There are no corresponding chart abstracted measures. These measures are not required for 2023 2024 collection but are offered as an optional measures to meet ORYX eCQM requirements.

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title1.4: What measures are available for reporting in CY2023CY2024?

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/

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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.

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title1.7: When can we begin entering or uploading CY2023 data?

Please see the “Timeline” documentation under “Measurement”, “Resources” on our website “ORYX Performance Measurement Timeline” documentation for key dates and information. The DDSP for CY2023 is expected to open in July 2023.

https://wwwjointcommission-ddsp.jointcommission.org/measurement/resources/atlassian.net/wiki/spaces/DCS/pages/71008257/ORYX+Performance+Measurement+Timeline

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title1.8: Can we resubmit 1Q2021 or 2Q2021 data?

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

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title1.9: 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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