For ORYX Reporting purposes, The Joint Commission determines hospital size based on licensed bed or outpatient visits as follows:

[HAP Large] Hospitals with ≥ 26 Licensed beds OR ≥ 50,000 Outpatient visits

[HAP Small] Hospitals with <26 Licensed beds AND <50,000 Outpatient visits

Large hospitals with no OB services are not required to submit any chart-abstracted measures, but may do so if they choose. There is no requirement or expectation to submit optional/substitute measures.

Large hospitals with OB services are able to meet the perinatal care (PC) measure requirement by submitting eCQM ePC measures per the annual requirements document.

Any facility required to submit eCQMs must submit all four (4)* quarters of eCQM data.

*Exception: For CY2024, in alignment with CMS, if eOP-40 is reported, only one (1) self-selected quarter is required and will count as a complete measure / towards meeting the eCQM requirement.

Organizations can no longer self-report data; all hospitals with ORYX Performance Measurement Requirements are required to submit data via the DDSP. The option to self-report (collecting data internally and making it available at the time of survey) was removed Effective CY2021. Requirements are posted on the “Measurement>Resources” section of our external website under “Supporting Materials” :
 https://www.jointcommission.org/measurement/resources/