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 CY2025, in alignment with CMS, if eOP-40 is reported, only two (2) self-selected quarters are 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/

Small hospitals and CAHs are not required to submit eCQMs but may do so if they choose in order to meet their minimum reporting requirements.

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

*Exception: For CY2025, in alignment with CMS, if eOP-40 is reported, only two (2) self-selected quarters are required and will count as a complete measure / towards meeting the eCQM requirement.

Small hospitals and CAHs are not required to collect data on the PC chart-abstracted measures to meet their ORYX reporting requirements. However, those facilities providing obstetrical services may elect to use any of the PC measures (chart-abstracted and/or eCQMs) to meet their reporting requirement if they provide obstetrical services.

Small hospitals and CAHs are not required to submit eCQMs but may do so if they choose in order to meet their minimum reporting requirements.

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

*Exception: For CY2025, in alignment with CMS, if eOP-40 is reported, only two (2) self-selected quarters are required and will count as a complete measure / towards meeting the eCQM requirement.

The Specialty Hospital designation as it relates to ORYX Performance Measurement was removed effective CY2021.  All hospitals previously designated as "Specialty" for ORYX reporting purposes are placed in the appropriate ORYX policy based upon number of Licensed Beds and/or Outpatient Visits. Please refer to the reporting requirements for the respective year on our website or copy and paste the following web address into your internet browser: https://www.jointcommission.org/measurement/reporting/accreditation-oryx/

For Joint Commission purposes, accredited general medical/surgical hospitals with inpatient psychiatric units or facilities who have a separate psychiatric hospital surveyed and accredited under the main Joint Commission accredited hospital are not required to report on the HBIPS measures. However, they may submit HBIPS measures if they choose. The CMS Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program includes inpatient psychiatric facilities and inpatient psychiatric units that bill under the Medicare Inpatient Psychiatric Facilities Prospective Payment System.

NOTE: For Joint Commission reporting purposes, when determining the patient population to be included and sampled, inclusions is for those patients receiving care in a psychiatric care setting. Please refer to the specifications for additional information. Documentation in the medical record should indicate that the patient was receiving care primarily for a psychiatric diagnosis in an inpatient psychiatric setting, i.e., a psychiatric unit of an acute care hospital or a free-standing psychiatric hospital. The allowable value for Psychiatric Care Setting may be determined electronically using a source such as an Electronic Record (EHR/EMR) or hospital billing system.

Hospitals submitting HBIPS must implement the Joint Commission’s HBIPS sampling requirements. CMS accepts the Joint Commission’s sampling requirements for their Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program.

A "Freestanding" Psychiatric Facility defined is a facility that is 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 #.

No; HBIPS-1 was retired for CY2023 (effective 1/1/2023) and is no longer available for selection. The remaining HBIPS measures (HBIPS-2, HBIPS-3, and HBIPS-5) remain required for “freestanding” psychiatric hospitals.

No; HBIPS-5 was retired for CY2024 (effective 1/1/2024) and is no longer available for selection. The remaining HBIPS measures (HBIPS-2, HBIPS-3) remain required for “freestanding” psychiatric hospitals.

There are currently no corresponding eCQMs available for selection by psychiatric facilities or inpatient psychiatric units. HBIPS, TOB, SUB, or IMM are only available as chart-abstracted measures and there are no corresponding eCQMs available for selection as additional measures for psychiatric facilities or inpatient psychiatric units.

Yes; As a participant in the ALC program, your organization(s) is required to submit data on the five ALC measures effective CY2024.

Refer to the ALC ORYX FAQs for additional information: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/79200257

Please refer to the reporting requirements for the respective year on our website or copy and paste the following web address into your internet browser: https://www.jointcommission.org/measurement/reporting/accreditation-oryx/

ORYX Performance Measurement Reporting Requirements remain suspended for the facilities listed below. Those organizations who identify ORYX measures applicable to their patient population may elect to submit ORYX data to The Joint Commission via the DDSP if they choose.

• Free-standing Children’s Hospitals

• Long Term Acute Care Hospitals (LTACHs)

• Inpatient Rehabilitation Facilities (IRFs)

• HCOs Participating in CMS PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

• Indian Health Service/Tribal

Not at this time.  The Joint Commission does currently not have available ORYX chart-abstracted or eCQM measures applicable to organizations with suspended ORYX requirements. At such time measures become available for consideration, the measures will be evaluated for use in the ORYX requirements for the Hospital Accreditation Program and these organizations will be notified if any new requirements are implemented.