APPLICABLE TO ALL JOINT COMMISSION ACCREDITED HOSPITALS WITH ORYX REQUIREMENTS:
If an organization submits optional measures 1Q2023, they are required to submit those measures for the remainder of the calendar year.
The Joint Commission has retained ED-1, IMM-2, and VTE-6 measures as “optional” (CMS retired these measures effective 1/1/2019).
If an HCO is required but unable to submit eCQMs, the HCO must submit an Extenuating Circumstance Request (ECR) form from The Joint Commission prior to the 1Q2023 chart-abstracted deadline; those HCOs granted an ECR for submission of eCQMS are required to submit three (3) chart-abstracted measures for all four (4) quarters of CY2023.
HCOs requesting extenuating circumstance for chart-abstracted measures must submit an ECR form prior to the deadline of the respective quarter’s data submission deadline.
The Joint Commission has not adopted the following CMS measures for 2023: SEP-1, Hospital Commitment to Health Equity, Screening for Social Drivers of Health, Screen Positive Rate for Social Drivers of Health.
APPLICABLE TO ACUTE CARE and CRITICAL ACCESS HOSPITALS:
For HCOs required or electing to submit eCQMs: HCOs are required to submit eCQM data for all four (4) quarters, applicable to the services provided and patient populations served.
Hospitals that do not provide Obstetrical Services are not required to submit alternate chart-abstracted measures but may do so if they wish.
APPLICABLE TO LARGE ACUTE CARE HOSPITALS WITH OBSTETRICAL SERVICES:
For ePC-07 Severe Obstetric Complications there is no corresponding chart abstracted PC-07 measure. This measure is not required for 2023 collection but is offered as an optional measure to meet ORYX eCQM requirements.
For any or all of the required chart-abstracted Perinatal Care Measures (PC-01, PC-02, PC-05 and PC-06), HCOs may submit the eCQM data (ePC01, ePC-02, ePC-05 and ePC-06) instead of the corresponding chart-abstracted measures.
NEW MEASURES for CY2023:
Hospital Harm—Severe Hypoglycemia Measure
Hospital Harm—Severe Hyperglycemia Measure
ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED)
RETIRED MEASURES effective 12/31/2023 and no longer available for CY2023
[HAP Large] Acute Care Hospitals that Provide Obstetrical Services
HAP Large are defined as ≥26 Licensed beds OR ≥ 50,000 Outpatient visits |
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[HAP Large] Acute Care Hospitals that DO NOT provide Obstetrical Services
HAP Large are defined as ≥26 Licensed beds OR ≥ 50,000 Outpatient visits |
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[HAP Small] Acute Care Hospitals
HAP Small are defined as <26 Licensed beds AND <50,000 Outpatient visits |
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[CAH] Critical Access Hospitals
[CAH] Critical Access Hospitals adhere to the CAH standards manual, and are a specific designation by the state as a critical access hospital in a rural area. |
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[HAP PSYCH] Freestanding Psychiatric Hospital
HAP PSYCH are defined as a "Freestanding" Psychiatric Facility licensed and separately accredited as freestanding psychiatric hospital; it is not a unit within a hospital that is surveyed at the same time as the hospitals and shares an HCO ID #. |
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Suspended Accreditation Programs
Suspended organizations may submit ORYX Performance Measures to The Joint Commission via the DDSP if they choose. |
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