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CY2024 ORYX Requirements for [HAP Large] Acute Care Hospitals that DO NOT provide Obstetrical Services

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How are [HAP Large] Acute Care Hospitals defined as it relates to ORYX Requirements?

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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.

See also: DDSP General: Verifying Data Submission & ORYX Requirements https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/106496001

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IMPORTANT NOTE: In addition to ORYX performance measurement data submission to The Joint Commission via the Direct Data Submission Platform, effective July 1, 2024, acute care hospitals who are required through a CMS program to participate in NHSN are also required to join The Joint Commission NHSN Group. Participation in this group gives Joint Commission access to the following measures with no patient identifiers: CAUTI, CLABSI, CDI, MRSA Bacteremia, SSI: Colon, SSI: Hyst.

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  • eCQMs and Chart-abstracted measures are submitted for all 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 DO NOT Provide Obstetrical Services

REQUIRED MEASURES: The following one measure are is required:

Safe Use of Opioids (eCQM)

REQUIRED: In addition to the above required measure, your hospital must also submit a minimum of three (3) additional eCQMs applicable to patient population/services from those listed below:

eGMCS (eCQM) Global Malnutrition Composite Score (NEW)

eHH-01(eCQM) Hospital Harm—Severe Hypoglycemia Measure

eHH-02 (eCQM) Hospital Harm—Severe Hyperglycemia Measure

eHH-03 (eCQM) Hospital Harm—Opioid Related Adverse Events (NEW)

eOP-40 (eCQM) ST-Segment Elevation Myocardial Infarction

NOTE: If eOP-40 is reported, only one (1) self-selected quarter is required and will count as a complete measure / towards meeting the eCQM requirement.

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

eVTE-1 (eCQM) Venous Thromboembolism Prophylaxis

eVTE-2 (eCQM) ICU Venous Thromboembolism Prophylaxis

OPTIONAL AVAILABLE Chart-abstracted measures (CAM); hospitals may elected to submit any of the below measures if they choose. NOTE: Any chart-abstracted measure(s) submitted 1Q2024 are required to be submitted for the remainder of the calendar year.

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

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

SDOH-1 (CAM) Screening for Social Drivers of Health (NEW)

NOTE: SDOH measures are not submitted quarterly, but are instead submitted annually in alignment with the 4Q CAM submission deadline.

SDOH-2 (CAM) Screen Positive Rate for Social Drivers of Health (NEW)

NOTE: SDOH measures are not submitted quarterly, but are instead submitted annually in alignment with the 4Q CAM submission deadline.

SUB-2 (CAM) Alcohol Use Brief Intervention

SUB-3 (CAM) Alcohol & Drug Use Treatment at Discharge

TOB-3 (CAM) Tobacco Use Treatment at Discharge

VTE-6 (CAM) Hospital Acquired Potentially-Preventable VTE

See also: ORYX FAQs Measure Requirements: By Organization Type:https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/37486764