CY2025 ORYX Requirements for [CAH] Critical Access Hospitals
How are [CAH] Critical Access Hospitals defined as it relates to ORYX Requirements?
[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. For more information on CAH eligibility, contact your Joint Commission Account Executive and/or see also the accreditation health care settings on The Joint Commission Website.
For The Joint Commission, ORYX performance measurement requirements are specifically applicable to organizations accredited under the Critical Access Hospital (CAH) manual.
NOTE: In addition to required ORYX performance measurement data submission to The Joint Commission via the Direct Data Submission Platform, effective July 1, 2024, critical access hospitals may elect to join The Joint Commission NHSN Group if they choose. 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 12. NHSN Group for The Joint Commission
eCQMs and Chart-abstracted measures are submitted for all four (4) quarters unless otherwise noted.
Critical Access Hospitals are not required to submit PC measures but may do so if they choose if obstetrical services are provided.
In order to meet ORYX requirements, submitted measures must be applicable to patient population/services offered.
Critical Access Hospitals (CAH) |
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REQUIRED: Submit a minimum of one (1) eCQM plus two additional measures (chart-abstracted measures and/or eCQMs) applicable to patient population/ services offered.
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REQUIRED: Your hospital must submit a minimum of one (1) eCQM applicable to patient population/services from those listed below: |
IP-ExRad (eCQM) Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Inpatient) (NEW) |
OP-ExRad (eCQM) Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Outpatient) (NEW) NOTE: If OP-ExRad is reported, one (1) self-selected quarter is required and will count as a complete measure / towards meeting the eCQM requirement |
HH-PI (eCQM) Hospital Harm - Pressure Injury (NEW) |
GMCS (eCQM) Global Malnutrition Composite Score |
HH-HYPO (eCQM) Hospital Harm—Severe Hypoglycemia Measure |
HH-HYPER (eCQM) Hospital Harm—Severe Hyperglycemia Measure |
HH-ORAE (eCQM) Hospital Harm—Opioid Related Adverse Events |
OP-40 (eCQM) ST-Segment Elevation Myocardial Infarction (STEMI) NOTE: If OP-40 is reported, two (2) self-selected quarter are required and will count as a complete measure / towards meeting the eCQM requirement. |
PC-01 (eCQM) Elective Delivery |
PC-05 (eCQM) Exclusive Human Milk Feeding |
PC-06 (eCQM) Unexpected Complications in Term Newborns |
PC-07 (eCQM) Severe Obstetric Complications |
Safe Use of Opioids (eCQM) Safe Use of Opioids - Concurrent Prescribing |
STK-2 (eCQM) Discharged on Antithrombotic Therapy |
STK-3 (eCQM) Anticoagulation Therapy Atrial Fibrillation/Flutter |
STK-5 (eCQM) Antithrombotic Therapy by End of Hospital Day 2 |
VTE-1 (eCQM) Venous Thromboembolism Prophylaxis |
VTE-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 the first quarter of the calendar year are required to be submitted for the remainder of the calendar year unless otherwise noted. |
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 |
PC-01 (CAM) Elective Delivery |
PC-02 (CAM) Cesarean Birth |
PC-05 (CAM) Exclusive Human Milk Feeding |
PC-06 (CAM) Unexpected Complications in Term Newborns |
SDOH-1 (CAM) Screening for Social Drivers of Health 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 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 |
See also: ORYX FAQs Measure Requirements: By Organization Type: 5. Measure Requirements: By Organization Type
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