• APPLICABLE TO SMALL HOSPITALS & CRITICAL ACCESS HOSPITALS

  • Effective CY2025, small hospitals and critical access hospitals are required to submit a minimum of one (1) eCQM for the entire calendar year, plus two additional measures (Chart-abstracted, eCQM, or combination of both) applicable to their patient population and services offered.

• REMINDER: 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.

  • i.e. we no longer stratify OB requirements based on 1-299 or 300+ live births annually.

• REMINDER: effective January 1, 2024, The Joint Commission implemented 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.

  • Note: This is not retroactive to years prior to 2024; if an organization has ORYX requirements but does not submit required ORYX data via the DDSP, nor requests and receive an extenuating circumstance from The Joint Commission, and is non-responsive to our reminders to submit data or an ECR for two consecutive years (e.g. 2024 and 2025) they could receive a denial of accreditation for non-compliance.

• REMINDER: Effective July 1, 2024, acute care hospitals who are required through a CMS program to participate in NHSN are required to join The Joint Commission NHSN Group. The Group gives The Joint Commission access to the following measures with no patient identifiers: CAUTI, CLABSI, CDI, MRSA Bacteremia, SSI: Colon, SSI: Hyst. To request directions on how to join The Joint Commission NHSN Group, contact: hcooryx@jointcommission.org

  • Note: Critical Access Hospitals may participate if they choose.

The annual reporting requirements and list of available measures are available on the Measurement > Reporting part of our external website or copy and paste the following web address in your internet browser: https://www.jointcommission.org/measurement/reporting/accreditation-oryx/

Retired: Effective 1/1/2025 patient discharges and applicable to CY2025 ORYX Requirements, The Joint Commission retired:

• Chart-abstracted measure:

  • VTE-6: Hospital Acquired Potentially-Preventable Venous Thromboembolism

• eCQMs:

  • No eCQMs were retired for CY2025 for The Joint Commission

Added: Effective 1/1/2025 patient discharges and applicable to CY2025 ORYX Requirements, The Joint Commission added:

• Chart-abstracted measures:

  • no new chart-abstracted measures were added for CY2025 for The Joint Commission

• eCQMs:

  • eCQM: Excessive Radiation Dose or Inadequate Image Quality for Computed Tomography (CT) in Adults (Outpatient) (OP-ExRad)

  • Note: IP-ExRad was removed as an optional available measure for CY2025 for The Joint Commission.

CMS is the steward for these measures and the specifications are available on the eCQI Resource Center. These measures are not required for 2025 collection but are offered as an optional measures to meet ORYX requirements.

The CY2025 reporting requirements and list of available measures are available on our the Measurement > Reporting part of our external website or copy and paste the following web address in your internet browser: https://www.jointcommission.org/measurement/reporting/accreditation-oryx/

Per the description in your Joint Commission Connect eApp/General Application under Hospital site information > “Volume”, outpatient visits: Includes all clinics, outpatient surgery, physical therapy, radiology. Excludes all Laboratory tests.

No; Effective 1/1/2021 patient discharges, we removed the option of self-reporting data. All organizations with ORYX requirements must submit eCQM and/or chart-abstracted data to The Joint Commission via the Direct Data Submission Platform (DDSP). Hospitals that previously self-reported data are required to submit their data via the DDSP.

Please see the “ORYX Performance Measurement Timeline” documentation for key dates and information.

https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/71008257/ORYX+Performance+Measurement+Timeline

Effective CY2023 data, chart-abstracted measures can be resubmitted if an organization identifies errors in previously entered data. For more information on resubmission, see the Resubmission help topic: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/141295632

•(Large) Acute Care Hospitals are defined as having Licensed Beds >= 26 OR Outpatient Visits >= 50,000

•(Small) Acute Care Hospitals are defined as having Licensed Beds <26 AND Outpatient Visits < 50,000

•Critical Access Hospital (CAH) Accreditation Program reporting requirements are not defined by Licensed Beds / Outpatient Visits, and are not required to submit perinatal care measures regardless of if they have an obstetrical unit - but may do so if they choose

•Freestanding Psychiatric Facility reporting requirements are not defined by Licensed Beds / Outpatient Visits and are required to submit chart-abstracted HBIPS measures plus one additional self-selected measure

•The Specialty Hospital designation was removed effective CY2021; all hospitals previously designated as "Specialty" for ORYX reporting purposes were placed in the appropriate ORYX policy based upon Licensed Beds and/or Outpatient Visits.

Refer to the annual reporting requirements and list of available measures applicable to each setting/service on the Measurement > Reporting part of our external website or copy and paste the following web address in your internet browser: Accreditation - ORYX