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In April The Joint Commission will send an e-mail to acute care hospitals with information
about joining the National Healthcare Safety Network (NHSN) Group. The e-mail will be sent
to the primary accreditation contact and/or the ORYX® contact listed on the organization’s
secure Joint Commission Connect® extranet site.

The January 2024 issue of Perspectives announced that, beginning July 1, 2024, acute
care hospitals with ORYX performance measurement requirements that have to participate
in the NHSN system through a US Centers for Medicare & Medicaid Services (CMS) program,
must join the Joint Commission NHSN Group. Participation in the Joint Commission NHSN
Group is optional for critical access hospitals where participation in CMS programs is not
required.

Sign-Up Milestones and Troubleshooting

The following table provides the timeline of sign-up tasks.

Please note that health care organizations that filter e-mails must whitelist* all e-mail from
the @jointcommission.org domain to ensure that they receive all communications from The
Joint Commission. Specifically, communication from the following must be accepted:

• The NHSN invitation: hcooryx@jointcommission.org

• The Joint Commission primary domain: @jointcommission.org

• The Joint Commission ORYX support: hcooryx@jointcommission.org

Organization contacts that do not receive the e-mail about joining the Joint Commission
NHSN Group by the second week in April 2024 should check junk/spam/clutter folders and/
or work with internal information technology staff to verify the e-mail is not blocked by a
firewall. Contact the ORYX Help Line if these troubleshooting suggestions fail to locate the
e-mail; please remember to provide your health care organization (HCO) identification (ID)
number in the e-mail

*A whitelist is a list of e-mail addresses or domain names from which an e-mail–blocking program will allow messages to be received. E-mail–
blocking programs, also called spam filters, are intended to prevent most unsolicited e-mail messages (spam) from appearing in subscriber inboxes.
If you are uncertain how your HCO handles whitelisting, please contact your internal information technology staff.

Dear Colleague:

This is a reminder for those organizations required or electing to submit eCQM data to The Joint Commission to meet their CY2023 ORYX requirements. Please note this email is sent to all organizations regardless of organization’s current submission status within The Joint Commission Direct Data Submission Platform (DDSP).

The Joint Commission deadline for submitting CY2023 eCQM data to the DDSP is March 15, 2024 at 11:59 PM Central Time. We strongly encourage organizations to submit their data well in advance of the deadline.

It is important for organizations to verify that their data is processed and submitted accurately and on time and retain a copy of their Submission Report. Organizations electing to use consultants or vendors to assist with the data submission process on the DDSP should have their own staff log into the platform to verify that data has been submitted as expected. Joint Commission staff cannot confirm this for you.

ADDITIONAL INFORMATION

• The Joint Commission and CMS are separate entities with separate requirements and platforms; submission of data to one does not meet the requirements of the other.

• Information on how to verify your organization’s ORYX requirements and data submission is available via the DDSP “Need Help?”: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/106496001

• Once data submission is complete, download the Submission Report from the Home page on the DDSP, which provides a summary / proof of submission of the data received from your organization.

• Organizations are responsible for managing user’s access to the DDSP. Staff with access to the DDSP log in via The Joint Commission website: https://www.jointcommission.org/login/

• CY2023 ORYX Performance Measurement Requirements: https://www.jointcommission.org/measurement/reporting/accreditation-oryx/

• Please see the timeline on our website for the phases and calendar years of the platform go-live and when data is due under "Supporting Materials": https://www.jointcommission.org/measurement/resources/

Questions
If you need assistance or have questions with any portion of the Platform, please submit a support ticket via the DDSP “Need Help?” button.

If you have non-DDSP questions, please contact hcooryx@jointcommission.org and include your HCO ID in the subject line.

Thank you
 

Downloadable PDF of communication: 

Dear Colleague, 

The purpose of this communication is to inform you that the Joint Commission will be deleting CY2022 QRDA-I files from the DDSP servers effective 4/12/2024.  

Once the CY2022 QRDA-I files have been removed from the DDSP, users will not be able to view patient level data in the Source Viewer and Logic Explorer debugging tools accessible via the magnifier icon. In addition, the magnifier icon on the Upload Data - Upload Summary page will not function. 

This will not affect DDSP users’ ability to view/download their CY2022 Data Submission Reports from the Home page, Patient Result detail report on the Quality Improvement page, or Error and Warning report on the Data Accuracy page.   In addition, there is no impact to submitted data saved in the DDSP database. 

Hospitals that would like to review their CY2022 eCQM data in Source Viewer or Logic Explorer for debugging purposes need to act before Friday, April 12, 2024. 

Please note, moving forward, QRDA-I files for each annual submission will be removed 6 months after close of the submission period. Therefore, 2023 QRDA-I files will be removed in September 2024. 

Note that the 2021 QRDA-I Files have already been removed and while the DDSP debugging tools to review these files cannot be used anymore, however, the Patient Result detail reports, Error and Warning reports, Data Submission Reports, and the dashboard views are available.  

If you have any questions, please submit a support ticket via the “Need Help?” button on the DDSP. 

Thank you 

Downloadable PDF of communication: 

Dear Colleague:

This is a reminder for all DDSP users. This email is sent to all organizations currently active on The Joint Commission Direct Data Submission Platform (DDSP), and regardless of the organization’s current submission status. Information on whether this applies to your organization and how to verify your organization’s ORYX requirements and submission status is provided below.  

Applicable to organizations required or electing to submit chart-abstracted data: The Joint Commission deadline for entering 4Q2023 chart-abstracted data to the DDSP is March 31, 2024 at 11:59 PM Central Time.

Applicable to organizations required or electing to submit eCQMs: The eCQM Submit button is now available in the eCQM Module on the Submit Data page.  The deadline to submit  of CY2023 eCQM data is March 15, 2024 at 11:59 PM Central Time.   

We strongly encourage organizations to enter or submit their data well in advance of the deadline. It is important for organizations to verify that their data is entered/submitted accurately and on time. Joint Commission staff cannot confirm this for you. Organizations electing to use consultants or vendors to assist with the data entry process on the DDSP should have their own staff log into the platform to verify that chart-abstracted data has been entered as expected. 
 
ADDITIONAL INFORMATION 

• The Joint Commission and CMS are separate entities with separate requirements and platforms; submission of data to one does not meet the requirements of the other. 

• Information on how to verify your organization’s ORYX requirements and data submission is available via the DDSP “Need Help?”: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/106496001  

• Users on the DDSP should download and retain for record the Submission Report from the Home page on the DDSP, which provides a summary / proof of submission of the data received from your organization to date.  

• Organizations are responsible for managing user’s access to the DDSP. Staff with access to the DDSP log in via The Joint Commission website: https://www.jointcommission.org/login/  

• Guide for Data Entry of Chart-Abstracted Measures into the DDSP: https://www.jointcommission.org/measurement/specification-manuals/chart-abstracted-measures/ 

• CY2023 ORYX Performance Measurement Requirements: https://www.jointcommission.org/measurement/resources/Supporting Materials 

• Please see the timeline on our website for the phases and calendar years of the platform go-live and when data is due under "Supporting Materials": https://www.jointcommission.org/measurement/resources/ 

Questions 
If you need assistance or have questions with any portion of the Platform, please submit a support ticket via the DDSP “Need Help?” button. 
 
If you have non-DDSP questions, please contact hcooryx@jointcommission.org and include your HCO ID in the subject line.  
 
Thank you 

Downloadable PDF of communication: 

Dear Colleague: 

This is a correction specifically applicable to Critical Access Hospitals regarding the CY2024 ORYX Performance Measurement Requirements. 

Correction: Participation in the Joint Commission National Healthcare Safety Network (NHSN) Group is optional for Critical Access Hospitals where participation in CMS programs is not required. 

Please note onboarding information to opt-in to The Joint Commission NHSN Group will be provided to all organizations, including Critical Access Hospitals, in CY2024. Critical Access Hospitals may elect to participate in The Joint Commission NHSN Group if they choose. 

For information regarding The Joint Commission CY2024 ORYX requirements, please see the CY2024 requirements document posted on The Joint Commission website: https://www.jointcommission.org/measurement/reporting/accreditation-oryx/  

QUESTIONS  
If you have questions, please contact hcooryx@jointcommission.org and include your HCO ID in the subject line.  
 
Thank You 

Downloadable PDF of communication: 

Dear Colleague: 

The Joint Commission updated the CY2024 ORYX^® Performance Measure reporting requirements effective January 1, 2024. These updates affect reporting requirements for Joint Commission–accredited critical access hospitals and hospitals.

Key 2024 updates include the following:

• Effective January 1, 2024, The Joint Commission is implementing a new decision rule applicable to hospitals and critical access hospitals with ORYX performance measurement requirements, 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. See Key Communications for additional information.

• Acute care hospitals and critical access hospitals will be required to join the Joint Commission National Healthcare Safety Network (NHSN) Group. Information on the process to join The Joint Commission NSHN group will be distributed during late 2023 and early 2024. See the November Perspectives^® article for additional information.

• Two new electronic clinical quality measures (eCQMs) will be available to meet ORYX eCQM submission requirements.

  • Hospital-Harm—Opioid Related Adverse Events eCQM (HH-ORAE)

  • Global Malnutrition Composite Score eCQM (GMCS)

• Two new chart-abstracted measures will be available to meet ORYX measure submission requirements:

  • Screening for Social Drivers of Health (SDOH-1)

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

• The Joint Commission will retire four measures beginning January 1, 2024:

  • Chart-abstracted Hospital-Based Inpatient Psychiatric Services - Multiple Antipsychotic Medications at Discharge with Appropriate Justification (HBIPS-5)

  • Chart-abstracted Tobacco Treatment Measures - Tobacco Use Treatment Provided or Offered (TOB-2) and Tobacco Use Treatment (TOB-2a)

  • eCQM Emergency Department (ED) - Admit Decision Time to ED Departure Time for Admitted Patients (eED-2)

  • eCQM Stroke - Discharged on Statin Medication (eSTK-6) [Note: the chart-abstracted STK-6 measure remains required for applicable Stroke certification programs]

• Applicable to [Large] Hospitals (HAP) with ≥26 Licensed beds OR ≥50,000 Outpatient visits AND Provide Obstetrical Services:

  • Perinatal Care (PC) requirements will no longer be based on annual live birth volume; PC requirements apply to [Large] Hospitals (HAP) that provide obstetrical services.

Please review the detailed list of all requirements and measures by organization type for CY2024 via The Joint Commission’s ORYX Performance Measurement Reporting page.

Specifications for Joint Commission chart-abstracted measures are available on Specification section of The Joint Commission’s ORYX Performance Measurement page.

Specifications for eCQMs are available on the Electronic Clinical Quality Improvement (eCQI) Resource Center website.

Questions regarding these updates and requirements may be directed to the ORYX Help Inbox. Please include your HCO ID # in the subject line of all inquiries.

Thank You

Downloadable PDF of communication: 

Dear Colleague,

Effective January 1, 2024, The Joint Commission is implementing a new decision rule for critical access hospitals and hospitals to reinforce the requirement to participate in the ORYX® performance measurement initiative. The ORYX initiative is an integral part of Joint Commission accreditation. Compliance with the initiative supports an organization’s continuous quality improvement efforts by monitoring key performance areas.

Annual ORYX performance measure reporting is required by Accreditation Participation Requirement (APR) Standard APR.04.01.01, Element of Performance (EP) 24. With the new decision rule, organizations may receive a Denial of Accreditation (DA) if they fail to meet ORYX performance measure reporting requirements for two consecutive years.

Beginning with calendar year (CY) 2024 ORYX performance measurement data, if an accredited organization does not submit performance measures for a calendar year, it will receive a notification that it either needs an approved Extenuating Circumstance Request (ECR) for the year or to submit performance measures. If the organization still has not submitted performance measures at the close of a second calendar year, it may receive a Denial of Accreditation, regardless of where the organization is in its accreditation cycle. Organizations experiencing emergency or disaster incidents, changes to their electronic health record systems, or other circumstances that create a significant burden for quality reporting may request an exemption for the ORYX reporting requirements by completing and returning The Joint Commission ECR form available within the ORYX FAQs or via the DDSP “Need Help?”.

Additional information on the Joint Commission’s ECR process and submission deadlines are available in the ORYX FAQs repository. The Joint Commission’s ECR process differs from the US Centers for Medicare & Medicaid Services’ (CMS) exemption request process, so it is important to review the ORYX FAQs prior to established deadlines.

The decision rule will be published in the fall 2023 E-dition update to the Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH) and the Comprehensive Accreditation Manual for Hospitals (CAMH). For those customers who purchase them, the 2024 hard-copy CAMCAH and CAMH will include the new decision rule.

For more information and a detailed list of all requirements and measures, visit The Joint Commission’s ORYX Performance Measurement Reporting page. The Joint Commission will post additional 2024 ORYX reporting requirements in a future issue of Perspectives. Questions regarding the new decision rule may be directed via email to hcooryx@jointcommission.org.

Thank you

Downloadable PDF of communication:

Dear Colleague:   

If you are receiving this communication, your organization has CY2023 ORYX Performance Measurement Requirements to submit chart-abstracted and/or eCQM data to The Joint Commission via the Direct Data Submission Platform (DDSP).

The DDSP chart-abstracted measure (CAM) module opens 12:00 pm Central Time on July 31, 2023.  

• The CAM module will open for 1Q and 2Q data entry on July 31, 2023

  • The deadline to submit 1Q and 2Q CAM data has been extended to December 31, 2023.

• The CAM module will open for 3Q data entry on September 1, 2023

  • The deadline to submit 3Q CAM data is December 31, 2023

• The CAM module will open for 4Q data entry on November 1, 2023

  • The deadline to submit 4Q CAM data is March 31, 2024

• The CY2023 eCQM module will open September 1, 2023

  • The deadline to submit CY2023 eCQMs is March 15, 2024

Additional information regarding the ORYX Performance Measurement Timeline (including important dates for CY2023 data submission) is available on the “Measurement” section of the external Joint Commission website under “Supporting Materials”:

https://www.jointcommission.org/measurement/resources/

Additional Information:
Existing DDSP users access the platform via the Joint Commission Website “Login” button: https://www.jointcommission.org/login/  

ORYX Performance Measurement Requirements:
https://www.jointcommission.org/measurement/reporting/accreditation-oryx/

ORYX Frequently Asked Questions:

https://www.jointcommission.org/measurement/oryx-faqs/

Recorded on-demand “How to” demo videos available within the DDSP via the Need Help? button under “Education Learning Resources > "How To" Demo Videos : https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/7602177

Office Hours for eCQMs and Chart-Abstracted Measures
The Joint Commission continues to offer DDSP Office Hours. Office Hours are a webinar format, with the ability to ask questions via the chat function. The content of the webinars for Office Hours includes tips for successful use of the platform and submission of data.  The webinar is staffed by Joint Commission staff to answer questions. Prior Office Hours webinars are recorded and available via the DDSP “Need Help” link via the “Education Learning Resources” tab.
 

Questions
If you need assistance or have questions with any portion of the Platform, please submit a support ticket via the DDSP “Need Help?” link.

If you have non-DDSP questions, please contact : hcooryx@jointcommission.org and include your HCO ID in the subject line. 

Thank you

Downloadable PDF of communication:

Dear Colleague:

The Direct Data Submission Platform for submission of CY2022 eCQM and/or chart-abstracted data is delayed and will be available by late January 2023.

A notification will be provided when the platform becomes available.

If you have any questions in advance of this deadline, please submit a support ticket via the “Need Help?” button on the DDSP or e-mail hcooryx@jointcommission.org.

Thank you

Downloadable PDF of communication:

Dear Colleague:

The Direct Data Submission Platform (DDSP) Electronic Clinical Quality Measure (eCQM) module opens at 12:00 pm Central Time on October 3, 2022 for CY2021 data submission. This communication is applicable to organizations required or electing to submit CY2021 eCQM data to The Joint Commission.

The deadline to submit CY2021 eCQM data is December 31, 2022.

Accessing the Direct Data Submission Platform (DDSP) Existing users access the DDSP via the Joint Commission Website “Login” button: https://www.jointcommission.org/

For new users, please look for your invitation email, which contains the link to the DDSP. The organization’s DDSP security administrator must grant access to the eCQM Module from Invite and Manage Users (link is on the left hand menu).

• Once on the DDSP, if you have any questions, please submit a support ticket via the 'Need Help?' button

• Multi-factor Authentication to access the DDSP is required. Please review the guidance documentation for MFA available here:

  • https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/24707087/

  • We encourage organizations to work with their internal IT departments to install and understand the use of MFA applications.

Certain eCQM functionalities will not be available for the October 3 “go live”, however, application functionalities will be added over time. When these features become available you will be notified by the Important Updates section of the Home Page. Users can upload and review measure results at this time, but the Submit functionality and Submit Report is not yet available and will be accessible with the coming releases before the CY2021 deadline. The eCQM known issues list is provided on the DDSP under “Need Help?”.

Additional Information:

Please review ORYX requirements via our website: https://www.jointcommission.org/measurement/reporting/accreditation-oryx/

Timeline

Please see the ORYX Performance Measurement timeline on our website under “Supporting Materials” for important dates for CY2022 data submission.

Office Hours for eCQMs and Chart-Abstracted Measures

The Joint Commission continues to offer DDSP Office Hours. Office Hours are a webinar format, with the ability to ask questions via the chat function. The content of the webinars for Office Hours includes tips for successful use of the platform and submission of data. The webinar is staffed by Joint Commission staff to answer questions.

Downloadable PDF of communication:

Sent September 21, 2022

Dear Colleague:

The Joint Commission updated the 2023 ORYX® Performance Measure reporting requirements effective January 1, 2023. These updates affect reporting requirements for Joint Commission–accredited critical access hospitals and hospitals. Key updates include:

• 3 New eCQMs will be available to meet ORYX eCQMs submission requirements:

  • Hospital Harm - Severe Hypoglycemia Measure

  • Hospital Harm - Severe Hyperglycemia Measure

  • Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED)

• Hospitals that are required or elect to submit eCQMs are required to submit eCQM data on a minimum of four (4) eCQMs for all four quarters starting with 2023 discharges

• The Joint Commission will retire chart-abstracted HBIPS-1

Additionally, CMS and The Joint Commission will both include maternal care eCQMs ePC-02 and ePC-07 as optional measures for the 2023 measure collection year. The Joint Commission made these measures available as optional measures to satisfy 2022 ORYX Performance Measure requirements. Specifications for the 3 new eCQMs as well as ePC-02 and ePC-07 are available on the eCQI Resource Center.

For more information and a detailed list of all requirements and measures, visit The Joint Commission’s Performance Measurement page. Questions may be directed to hcooryx@jointcommcommission.org.

Thank You

Downloadable PDF of communication:

Sent August 1, 2022

Update: The Joint Commission’s New Direct Data Submission Platform

ORYX® Measure Submission Timelines Established

On July 5, 2022, The Joint Commission’s in-house Direct Data Submission Platform (DDSP) onboarding began for organizations to accept their initial invitation to access the new platform (see the June 2022 issue of Perspectives for additional information related to the new DDSP). The following timelines provide the dates health care organizations are required to report their ORYX® performance measures.

Calendar Year (CY) 2021 Data Submission Timeline

• July 5–8, 2022: Initial invitations were sent to organizations’ Signatory Authority for onboarding to the new platform.

• August 1, 2022: DDSP chart-abstracted measure module opens, allowing health care organizations to enter their remaining CY2021 chart-abstracted measure data.

• October 3, 2022: DDSP electronic clinical quality measure (eCQM) module opens, allowing health care organizations to upload and submit their CY2021 eCQM data.

• December 31, 2022: Deadline to submit CY2021 chart-abstracted measure and eCQM data.

Calendar Year 2022 Data Submission Timeline

• January 2, 2023: DDSP chart-abstracted measure and eCQM modules open to allow healthcare organizations to enter CY2022 chart-abstracted measure data and upload and submit eCQM data.

• March 15, 2023: Deadline to submit CY2022 eCQM data.

• April 30, 2023: Deadline to submit CY2022 chart-abstracted measure data.

Calendar Year 2023 Data Submission Timeline

• May 2023: DDSP available for CY2023 data submission of 1Q2023 chart abstracted measure data and CY2023 eCQM data.

Additional Resources:

Health care organizations can visit the Measurement Resources page under “Supporting Materials” on The Joint Commission’s website for additional information, including important opening dates, data submission deadlines, and upcoming webinars. In addition, the recording, slides, and transcript are available on the Pioneers in Quality® General Sessions page for the Joint Commission’s Direct Data Submission Platform informational webinar that was held in June.

For more information and a detailed list of all ORYX requirements and measures, visit the Performance Measurement page on The Joint Commission’s external website.

Downloadable PDF of communication:

Dear Colleague,

The Joint Commission has been working to develop in-house capability for performance
measurement data submission. To accelerate this work, we are contracting with Dynamic
Health IT (DHIT) to support the development of a new Direct Data Submission Platform
(DDSP) and electronic clinical quality measure (eCQM) engine.

The DDSP will enable the submission of quality measurement data directly to The Joint
Commission from the approximately 3,500 accredited critical access hospitals and hospitals
that are required to submit this data to meet accreditation requirements. The DDSP will also
provide accredited hospitals with near real-time eCQM performance data.

DHIT will develop the platform underpinning the DDSP and apply its CQMsolution® – an
Office of the National Coordinator for Health Information Technology (ONC) certified Clinical
Quality Language measure engine – to calculate, display and generate eCQMs. The Joint
Commission will develop the chart-abstracted measure (CAM) engine and provide customer
support.

The new platform will be available in the second half of 2022. Accredited organizations
familiar with The Joint Commission’s previous DDSP will note few changes to the look and
feel of the new platform. We look forward to unveiling the new platform to continue to enable
chart-abstracted and eCQM measure submission.

While the platform is under development, ORYX® performance measurement requirements
are not suspended. Hospitals must continue to collect and aggregate their ORYX data
consistent with the Specifications Manual for Joint Commission National Quality Measures
and the Joint Commission Guide for Data Entry of Chart-Abstracted Measures. In addition,
organizations must continue to trend their ORYX measurement data for performance
improvement and, if applicable, be prepared to provide this data during survey.

A save the date for an introductory webinar about the platform will be sent in May and the
on-boarding process is anticipated to begin in June. A detailed timeline for all webinars, and
deadlines for CY2021 and CY2022 data submission will be provided in mid-2022.
Organizations also will be able to access on-demand online education throughout the launch
of the platform.

As a reminder, the data submission timeline and DDSP delay does not affect data submitted
for certification programs via the Certification Measure Information Process (CMIP) tool on
The Joint Commission Connect® extranet site. There are no changes to the certification data
submission timelines for 2021 or 2022. In addition, this delay does not affect the hospitals’
measurement requirements for data submission to the Centers for Medicare & Medicaid
Services (CMS).

For more information and a detailed list of all ORYX requirements and measures, visit The
Joint Commission website.

Questions? Please contact hcooryx@jointcommission.org.

Downloadable PDF of communication:

A message from The Joint Commission:

Since 2018, hospitals have submitted performance measure data to The Joint
Commission through the Direct Data Submission platform (DDSP) developed
by Apervita in partnership with The Joint Commission. The platform has been
very successful as measured by customer satisfaction, reliability, and
processing speed. During 2021, approximately 3,500 of our accredited health
care organizations were scheduled to submit data for chart-abstracted and
electronic clinical quality measures (eCQM) through the platform, however,
this will be delayed.

On Sept. 19, 2021, Apervita notified us that they would cease all business at the
close of Sept. 30, 2021. As a result of their business decision, Joint Commission
DDSP users no longer have access to the platform. Due to the short notice, we
were not able to develop a mitigation plan to keep the DDSP operational. The
data that customers submitted to the platform should be accessible to us in the
future, but at this time customers cannot submit additional data.

Therefore, 2021 and 2022 Chart-abstracted and eCQM accreditation data
submission timelines will be delayed. The new Joint Commission DDSP is
being built to collect both chart-abstracted and eCQM data. Hospitals must
continue to collect, aggregate and trend their ORYX measurement data for
performance improvement and accreditation survey activities. We anticipate
that hospitals will submit their 2021 and 2022 data to the new DDSP in the
second half 2022. A more specific timeline will be communicated when the
platform launch date has been determined.

ORYX performance measurement requirements have not been suspended.
Organizations should continue ORYX performance measurement efforts and
be prepared to provide data at the time of survey.

This ORYX data submission delay does not impact Certification Programs data
submitted via the CMIP application on the Joint Commission Connect site.
There has been no change to the certification data submission timelines. In
addition, this in no way impacts hospitals’ requirements for data submission to
CMS.

The 2022 ORYX Requirements Document has been posted to The Joint Commission website; please refer to the posting for detailed information on the 2022 requirements.

Please send any questions to: hcooryx@jointcommission.org.

Downloadable PDF of communication:

Dear Colleague:

The Joint Commission is excited to share information about the 2021 ORYX Performance Measurement program. During 2020, hospitals used the Direct Data Submission Platform (DDSP) for submission of electronic clinical quality measure (eCQM) data directly to The Joint Commission and were given access to the chart-abstracted module on DDSP. Continuing forward in 2021, organizations have one place to submit both eCQM and chart-abstracted data. The Direct Data Submission Platform eases the burden and expense of submission and empowers organizations with data for quality improvement.

As communicated in September, the Joint Commission has streamlined and simplified ORYX policy requirements effective CY2021. The new modified policies integrate an organization’s EApp data to better define the applicable ORYX Policy. The ORYX Policies have been consolidated within the Direct Data Submission Platform (DDSP) to determine each organization’s associated ORYX requirements. An HCO’s ORYX requirements will be calculated by the number of Licensed Beds and/or volume of Outpatient Visits, instead of average daily census.

Joint Commission 2021 ORYX Requirements for Accreditation Purposes for eCQM and/or Chart-Abstracted data submission include the following:

• Acute Care Hospitals having Licensed Beds >= 26 OR Outpatient Visits >= 50,000 and 300+ live births annually submit four chart-abstracted measures (PC-01, PC-02, PC-05 and PC-06), and select a minimum of 4 eCQMs, reporting the same eCQMs for two self-selected quarters. There are twelve eCQMs available.

• Acute Care Hospitals having Licensed Beds >= 26 OR Outpatient Visits >= 50,000 and 1-299 live births annually submit one chart-abstracted measures (PC-01), and select a minimum of 4 eCQMs, reporting the same eCQMs for two self-selected quarters. There are twelve eCQMs available.

• Acute Care Hospitals having Licensed Beds >= 26 OR Outpatient Visits >= 50,000 and do not provide obstetrical service do not submit chart-abstracted measures, and select a minimum of 4 eCQMs, reporting the same eCQMs for two self-selected quarters. There are twelve eCQMs available.

• Hospitals having Licensed Beds <26 AND Outpatient Visits < 50,000 (small hospitals), are required to submit any combination of three (3) eCQMs and/or chart-abstracted measures applicable to patient population/services offered.

• Critical Access Hospitals (CAHs) are required to submit any combination of three (3) eCQMs and/or chart-abstracted measures applicable to patient population/services offered.

• Freestanding Psychiatric Hospitals continue to report on the four required Hospital-Based Inpatient Psychiatric Services (HBIPS) measures (HBIPS-1, HBIPS-2, HBIPS-3, and HBIPS-5).

• Free-standing Children’s Hospitals, Long Term Acute Care Hospitals (LTACHs), Inpatient Rehabilitation Facilities (IRFs) and HCOs participating in CMS PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) program reporting requirements remain suspended.

• The Joint Commission has eliminated “self-reporting” of ORYX data. Hospitals that selfreported performance measurement data in the past are now expected to submit their data, starting CY2021, to the Direct Data Submission Platform (DDSP).

For more information and a detailed list of all measures, visit the Measurement section of The Joint Commission website at: https://www.jointcommission.org/measurement/reporting/accreditation-oryx/

For questions, please contact us at hcooryx@jointcommission.org.

Thank for your continued partnership with The Joint Commission toward our shared goal of quality improvement through performance data measurement.

Downloadable PDF of communication:

Dear Colleague:

RE: Modifications to CY 2021 ORYX Policies

The Joint Commission has streamlined and simplified ORYX policy requirements effective CY2021. The new modified policies integrate an organization’s E-App data to better define the applicable ORYX Policy. The ORYX Policies have been consolidated within the Direct Data Submission Platform (DDSP) to determine each organization’s associated ORYX requirements. An HCO’s ORYX requirements will be calculated based upon the size of the organization as defined by the number of Licensed Beds and/or volume of Outpatient Visits, instead of average daily census.

Starting with CY 2021, for the Hospital Accreditation Program (HAP) and Critical Access Hospital Accreditation Program (CAH), ORYX data submission requirements include the following:

ORYX eCQM and/or Chart-Abstracted data submission:

• Acute Care Hospitals are now defined as having Licensed Beds >= 26 OR Outpatient Visits >= 50,000, and no longer defined by ADC >10

• Small Hospitals are now defined as having Licensed Beds <26 AND Outpatient Visits < 50,000, and no longer defined by ADC <= 10

  • See note below regarding Eliminating “self-reporting” of ORYX Data

• Freestanding Psychiatric Facility

  • No change to ORYX Policy

• Critical Access Hospital Accreditation Program

  • No change to ORYX Policy

  • See note below regarding Eliminating “self-reporting” of ORYX Data

• Eliminating “self-reporting” of ORYX data

  • With the enhanced functionality of the Direct Data Submission Platform (DDSP), all hospitals must submit eCQM and/or chart-abstracted data on the DDSP.

  • Hospitals that self-reported in the past are now expected to submit their data, starting with CY 2021, to the DDSP.

• Eliminating ORYX Designated Specialty Hospital

  • Effective CY 2021, this designation is removed from the ORYX program.

  • HCOs with this designation had services and/or populations that made it difficult to meet full ORYX policy requirements.

  • Starting with CY 2021, all hospitals will be placed in the appropriate ORYX policy based upon Licensed Beds and/or Outpatient Visits listed above.

  • The Department of Quality Measurement (DQM) will work with these organizations to determine how they can meet their full ORYX Policy requirements.

• Exemption for Extenuating Circumstance

  • If an HCO is unable to submit data for a defined time period due to an approved reason, (e.g., technology upgrade, natural disaster, merger in process), the HCO can request an exemption using the Extenuating Circumstance form and process.

  • Approved Extenuating Circumstances are reassessed annually.

Suspended ORYX Requirements

• The following facilities continue to have ORYX requirements suspended:

  • Freestanding Children’s Hospitals

  • Long Term Acute Care Hospitals (LTACHs)

  • Inpatient Rehabilitation Facilities (IRFs)

  • Acute care hospitals participating in CMS PPS-Exempt-Cancer Hospital Quality Reporting (PCHQR) Program

For more information:

• Visit the “Measurement” section of The Joint Commission’s website, ORYX Performance Measurement Reporting at http://www.jointcommission.org/performance_measurement.aspx

• Please contact us at hcooryx@jointcommission.org.

Specifics regarding the CY2021 ORYX requirements and measures will be shared with HCOs by the end of September 2020. In addition, The Joint Commission will be offering a Pioneers in Quality webinar regarding the CY2021 ORYX requirements in October.

Thank for your continued partnership with The Joint Commission toward our shared goal of quality improvement through performance measurement.

Department of Quality Measurement

The Joint Commission

Downloadable PDF of communication:

Dear Colleague:

The Joint Commission is excited to share information about the 2020 ORYX® Performance Measurement program. During 2019, all hospitals transitioned to the Direct Data Submission Platform (DDSP) for submission of electronic clinical quality measure (eCQM) data directly to The Joint Commission. In 2020, hospitals will use the Direct Data Submission Platform for submission of chart abstracted measures. Thus, in 2020, organization have one place to submit both eCQM and chart abstracted data. The goal of the Direct Data Submission Platform is to ease the burden and expense of submission, and empower organizations with data for quality improvement.

Joint Commission 2020 ORYX® Requirements for Accreditation Purposes

Electronic Clinical Quality Measure (eCQMs) Reporting Requirements for Hospital Accreditation Program (HAP) with an ADC > 10

• Acute Care Hospitals with an ADC >10 report a minimum of four self-selected eCQMs applicable to the services provided and patient populations served by the hospital, for a minimum of one selfselected quarter.

  • 10 eCQMs are available for selection (eED-2, ePC-01, ePC-02, ePC-05, eSTK-2, eSTK-3, eSTK-5, eSTK-6, eVTE-1, eVTE-2)

  • All hospitals utilize the Direct Data Submission (DDS) Platform for eCQM data submission.

Changes to Chart-Abstracted Submission Requirements starting with CY 2020 for Hospital Accreditation Program (HAP)

• Starting with CY 2020 chart-abstracted data, The Joint Commission no longer has contracts with ORYX chart-based vendors.

  • ORYX vendors, based on contractual language, are required to submit hospital’s 3rd and 4th quarter 2019 chart abstracted data in January and April 2020 using their current vendor data submission processes.

• For CY 2020 chart-abstracted data and forward, all hospitals submitting data will be transitioned to and utilize the Joint Commission’s DDS Platform.

  • Hospitals collect and report monthly chart-abstracted aggregate data on a quarterly basis for calendar year (CY) 2020 using the Joint Commission’s Direct Data Submission (DDS) Platform.

  • In early 2020, The Joint Commission will provide additional information concerning the transition to the DDS Platform.

Chart-Abstracted Measure Reporting Requirements for Acute Care Hospital Accreditation Program (HAP) with an ADC > 10

• Acute Care Hospitals with an ADC > 10 that provide Obstetrical Services report one required chart-abstracted measure, which is PC-01.

  • In addition, hospitals with at least 300 live births are also required to report on all chart-abstracted perinatal care measures; PC-02, PC-05 and PC-06.

  • Please note: Effective 1/1/2020, PC-03 and PC-04 have been retired from the Perinatal Care measures.

Freestanding Psychiatric Hospitals (HAP) Accreditation Program Reporting Requirements

• Freestanding Psychiatric Hospitals continue to report on the four required Hospital-Based Inpatient Psychiatric Services (HBIPS) measures (HBIPS-1, HBIPS-2, HBIPS-3, and HBIPS-5).

Critical Access Hospitals (CAHs), Small Hospitals (HAP with ADC of 10 or fewer inpatients), and ORYX Designated Specialty Program Reporting Requirements

• Critical Access Hospitals (CAHs), Small Hospitals (ADC ≤ 10) and ORYX Designated Specialty Hospitals continue to report on a choice of three available measures (selected measures can be chart abstracted or eCQM).

  • These hospitals remain exempt from requirement to submit data to The Joint Commission. If data are not submitted, the organization is required to make data reports available for review by surveyors during on-site surveys.

Hospital Accreditation Programs (HAP) for which ORYX Performance Measure Reporting Requirements continue to be suspended

• Suspension of requirements continues for freestanding children’s hospitals, long-term acute care hospitals, and inpatient rehabilitation facilities.

For more information:

• In early 2020, The Joint Commission will provide additional information concerning the transition of chart-based measure selection and submission to the DDS Platform.

• Visit the “Measurement” section of The Joint Commission’s website, ORYX Performance Measurement Reporting at http://www.jointcommission.org/performance_measurement.aspx

• Please contact us at hcooryx@jointcommission.org.

Thank for your continued partnership with The Joint Commission toward our shared goal of quality improvement through performance data measurement.

Division of Healthcare Quality Evaluation

The Joint Commission

Downloadable PDF of communication:

CERTIFICATION