• Effective January 1, 2024, The Joint Commission is implementing 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.

• 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.

If required but unable to submit any eCQMs for CY 2024, HCOs must submit an extenuating circumstance request (ECR) and receive an exemption from The Joint Commission. HCOs will be required to submit three (3) chart-abstracted measures for all four (4) quarters of CY2024.

See also: Extenuating Circumstances

• 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.

• Separately accredited Free-standing Psychiatric Hospitals are required to submit HBIPS-2, HBIPS-3, plus one additional measure from the measure list.

• Effective 1/1/2024, ALCs are required to participate in the ORYX Performance Measurement and submit data to The Joint Commission via the DDSP.

• Effective CY2024, The Joint Commission has implemented the following measures:

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

  • eCQM: Global Malnutrition Composite Score eCQM (GMCS)

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

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

    • SDOH measures are submitted annually in alignment with the 4Q CAM submission deadline.

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

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

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

• CAM: Tobacco Treatment Measures - Tobacco Use Treatment Provided or Offered (TOB-2) and Tobacco Use Treatment (TOB-2a)