ORYX BASICS

The Joint Commission’s ORYX initiative integrates performance measurement data into the accreditation process.  ORYX measurement requirements support Joint Commission accredited organizations in their quality improvement efforts.

The Joint Commission is more than just an accrediting body. We are actively engaged in helping organizations improve their patient safety and quality of care. As it relates to Performance Improvement, these quality and safety efforts are demonstrated by documenting elements of patient encounters, e.g. How long did it take for a patient with stroke symptoms to receive a head scan? How long did it take for a patient to arrive in the ED and be treated before being discharged or admitted?

Hospital’s document all aspects of the care provided by collecting data from those encounters.

Here’s an example: Pat the Patient arrives in the Emergency Department. Staff document the amount of time (in minutes) it takes from the time the physician decides to admit Pat into the hospital from the Emergency Department, until Pat leaves the Emergency Department to go to the inpatient unit.

Staff document this information in the medical record for all encounters that fit that criteria.

In our example, the median time for this to occur for a sampling of Emergency Department patients like Pat is 225 minutes over the course of the first quarter of the year.

MEASURE EXAMPLE - ED-2: Admit Decision Time to ED Departure Time for Admitted Patients: Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care. Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment.

Performance Measurement data is submitted to The Joint Commission by all organizations with ORYX performance measurement requirements. The data is analyzed by statisticians at The Joint Commission and feedback is provided to facilities via Accelerate PI Dashboards. Measures which meet the Joint Commission accountability criteria are published on Quality Check® (see question 3.1 for more information on Quality Check)

For the hospital, this information shows trends in the care provided on measures over time, as well as how the organization is performing compared to others. By providing feedback, hospitals can identify opportunities to improve patient safety and quality of care.

For the Joint Commission, this information is used to generate national benchmarks and identify opportunities for improvement in clinical topic areas. In addition, this information is available to surveyors, so they may discuss Performance Improvement efforts your organization may enact as a result of seeing trends or spikes in patient quality of care and outcomes.

Organizations begin collecting ORYX Performance Measurement data the first calendar quarter following the receipt of their accreditation decision letter:

If the letter is received between 10/1 and 12/31, begin collecting 1Q data effective 1/1 patient discharges
If the letter is received between 1/1 and 3/31, begin collecting 2Q data effective 4/1 patient discharges
If the letter is received between 4/1 and 6/30, begin collecting 3Q data effective 7/1 patient discharges
If the letter is received between 7/1 and 9/30, begin collecting 4Q data effective 10/1 patient discharges

Note: Organizations are encouraged to keep up to date on any changes in the ORYX requirements by reviewing recent issues of The Joint Commission Perspectives^® or by going to the “Measurement” area on The Joint Commission website: http://www.jointcommission.org.

As a condition of participation (APR.04.01.01) organizations collect performance measures to meet specified ORYX measure reporting requirements for accreditation. The Joint Commission’s ORYX initiative integrates performance measurement data into the accreditation process. ORYX measurement requirements support Joint Commission-accredited organizations in their quality improvement efforts.

Elements of performance:

1. The organization collects measures relevant to their patient population to meet its current ORYX requirements.

2. The organization discusses with the surveyor how the data are used to identify, prioritize, and monitor performance improvement activities.

3. The organization uses each individual measure to identify patterns, trends, or variations for improvement opportunities.

4. Based on Joint Commission statistical analysis, the organization continues to use a measure in performance improvement activities and determines if the data suggest an unstable pattern of performance or otherwise identify an opportunity for improvement.

5. The organization resolves data quality issues for reported performance measures.
   For the most recent 12-month calendar reporting period, the organization achieves and sustains an acceptable level of performance, as defined by Joint Commission statistical analysis, for each measure before it discontinues its use in performance improvement activities.

6. The organization ensures that organization-specific data for its performance measures are submitted to The Joint Commission, in accordance with timelines established by The Joint Commission.

THE JOINT COMMISSION & CMS

The Health Care Organization Identification number (HCO ID #) is not the same as CMS’ CCN. The HCO ID # is a unique number assigned by The Joint Commission. The Joint Commission’s HCO ID # can most easily be found when logged into your organization’s Joint Commission Connect Extranet site, shown in the upper right-hand corner, under the facility name and address.

The Joint Commission and CMS are separate entities with separate program requirements. The data is used for different purposes. There are no systems or infrastructure in place to share data between the two organizations.

The Joint Commission is aligned with CMS on the requirements of reporting 3 self-selected quarters of eCQM data for each of four self-selected eCQMs for CY2022. CMS has 9 eCQMs available for selection and The Joint Commission has 13 eCQMs available for selection. The Joint Commission offers the following additional eCQMs for selection: ePC-01, ePC-02, ePC-06, and new for CY2022 – eCQM only ePC-07. For CY 2022, CMS and The Joint Commission both utilize the chart-abstracted measure PC-01.

NOTE: The Joint Commission aligns with CMS requirements as closely as possible, however there are times when goals or program needs differ between the two entities and this necessitates variation.

The Joint Commission and CMS are separate entities. If you are not able to submit all/part of your measure requirements to The Joint Commission, you must also request an exception from TJC. Send an email to hcooryx@jointcommission.org to request an Extenuating Circumstance Request (ECR) form.  (Refer to question 2.9 regarding the additional requirements and timeline of ECR requests)

Hospitals who believe they have an extenuating circumstance that would impact eCQM and/or chart-abstracted data for accreditation purposes should request an Extenuating Circumstance Request (ECR) form via email to: hcooryx@jointcommission.org

IMPORTANT NOTE: Hospitals required but unable to submit eCQMs must request and be granted an exception prior to the deadline to submit 1Q2022 chart-abstracted data, as any organization unable to meet their eCQM requirement must submit three (3) chart-abstracted measures for all four (4) quarters of CY2022.

If a hospital believes they are unable to submit chart-abstracted measures (based on their requirements or optional annual reporting) for any reason, they should submit a request for extenuating circumstances thirty (30) days prior to the quarter close of the affected quarter(s).

Eligible hospitals and Critical Access Hospitals (CAHs) must submit a new application for any subsequent years and in no case may an eligible hospital or CAH be granted an exception for more than five consecutive years.

Chart-abstracted PC-01 is required to be reported for the CMS Hospital Inpatient Quality Reporting Program (HIQR). For The Joint Commission, any or all of the required chart-abstracted Perinatal Care Measures (PC-01, PC-02, PC-05 and PC-06) may be submitted or alternatively, HCOs may submit a minimum of three quarters of ePC eCQM data (ePC-01, ePC-02, ePC-05 and ePC-06*) instead of four quarters of the corresponding chart-abstracted measures. (Refer to Section 6: Perinatal Care for additional information)

*The new ePC-07 measure is optional and is not required.

COMMUNICATIONS

There are a few possible reasons why you may not receive ORYX email notifications:

1. ORYX email notifications are sent to the individuals documented within your hospitals Joint Commission Connect site. Notifications are primarily sent to the listed ORYX Contact, with additional notifications going to the Primary Accreditation Contact. If you are not listed as either the ORYX Contact or the Primary Accreditation Contact for your hospital, please contact on of your hospital’s Joint Commission Connect Site Administrators, as they are the only one with the authority to modify or add to your hospital’s list of contacts. They are denoted with a small “key” next to their name in Joint Commission Connect. If you do not have access to Joint Commission Connect, contact your Quality Director.

2. If you are a listed contact (i.e., ORYX or Primary Accreditation Contact), check to see if you have opted out of receiving emails from The Joint Commission. You may have opted out in one of two ways, either by checking the opt-out box on the “Security Admin” page on Joint Commission Connect and/or you have clicked the ‘One Click Unsubscribe’ link at the bottom of an email sent by The Joint Commission. Users that have Unsubscribed from receiving e-mails and want to opt back in, should contact hcooryx@jointcommission.org for assistance.

3. If you have not opted out of receiving emails, please check your junk/spam/clutter and also check with your internal IT department and ask if your hospital is using email filtering. Hospitals using email filtering need to whitelist (see definition below) specific domains and email addresses to ensure all communications are received.

For general Joint Commission communication, whitelist The Joint Commission Domain: @jointcommission.org

Definition: 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. Depending on your email software, emails may also go to a clutter/junk/spam/other folder.  If you are uncertain how your hospital handles whitelisting, please contact your internal information technology/systems staff.

ORYX and Performance Measurement: For questions related to ORYX measure requirements, extenuating circumstance requests, and related processes, send an email to: hcooryx@jointcommission.org; be certain to include your HCO ID # in the subject line.

Chart-Abstracted Specifications: Measure questions related to Joint Commission Specifications must be submitted to the Wiki Platform: https://manual.jointcommission.org/

Joint Commission supported eCQMs: eCQM questions related to Joint Commission supported eCQMs must be submitted to the Wiki Platform: https://manual.jointcommission.org/

eCQM Specifications: Measure questions related to eCQM specifications should be submitted by accessing support resources available on the Joint Commission website, or copy and paste the following web address in your internet browser: https://www.jointcommission.org/measurement/specification-manuals/electronic-clinical-quality-measures/

Direct Data Submission Platform (DDSP): When logged into the DDSP, select the “Need Help?” icon and review the available topics; if you are unable to find content related to your question or issue, submit a platform support ticket via the same menu.

FEES

Organizations with ORYX requirements are invoiced in January for the upcoming calendar year of ORYX data submission based upon organizational weighted volumes for both eCQMs and chart-abstracted submissions. The ORYX annual fees are billed as a separate invoice to allow flexibility to organizations internal payment processes. Staff with access to their Joint Commission Connect site may view their invoice: Survey Process > Contracts and Billing > Fee, Billing and Invoice Information

There are no separate fees for use of the data submission platform.

DEADLINES

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, the site hosted by Apervita for direct data submission of chart-abstracted measures and/or eCQMs shut down permanently, resulting in the inability for hospitals to submit ORYX performance measurement data to The Joint Commission. Due to this, chart-abstracted and eCQM accreditation data submission timelines for 2021 and 2022 data was delayed. A new Joint Commission Direct Data Submission Platform (DDSP) to collect both chart-abstracted and eCQM data is available the second half of CY2022. In the interim, hospitals continued to collect, aggregate and trend their ORYX measurement data for performance improvement and accreditation survey activities. Hospitals will submit past 2Q2021, 3Q2021, 4Q2021 and/or eCQM ORYX data and begin CY2022 data submission based on the published timeline.

An infographic on deadlines and target dates is posted on our website under, Measurement > Resources > Supporting Materials: Website

For CY2022 eCQM data, the annual submission deadline is March 15, 2023. eCQMs may be submitted anytime between when the CY2022 data submission period opens (expected in the second half of CY2022) up until the deadline (usually March 15th of the following year). As a reminder, eCQMs are currently submitted retrospectively, e.g., CY2022 eCQMs are due no later than March 15, 2023, and CY2023 eCQMs are due no later than March 15, 2024.