How are [HAP Large] Acute Care Hospitals defined as it relates to ORYX Requirements?
For The Joint Commission, ORYX performance measurement requirements are specifically applicable to organizations accredited under the Hospital Accreditation Program (HAP).
HAP Large are defined as ≥26 Licensed beds OR ≥ 50,000 Outpatient visits
Refer to your Joint Commission Connect Site eAPP Hospital Volume or view the DDSP HCO Characteristics Organization Requirements tab.
See also: General: Verifying Data Submission & ORYX Requirements https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/106496001
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.
See Also: 12. NHSN Group for The Joint Commission https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/143720449
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 |
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REQUIRED MEASURES: The following one measure are 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 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 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 |