[HAP Large] Acute Care Hospitals with Obstetrical Services (2024)

CY2024 ORYX Requirements for [HAP Large] Acute Care Hospitals with Obstetrical Services

How are [HAP Large] Acute Care Hospitals defined as it relates to ORYX Requirements?

For The Joint Commission, ORYX performance measurement requirements are specifically applicable to organizations accredited under the Hospital Accreditation Program (HAP).

HAP Large are defined as ≥26 Licensed beds OR ≥ 50,000 Outpatient visits

Refer to your Joint Commission Connect Site eAPP Hospital Volume or view the DDSP HCO Characteristics Organization Requirements tab for licensed bed / outpatient volume information.

IMPORTANT NOTE: In addition to ORYX performance measurement data submission to The Joint Commission via the Direct Data Submission Platform, effective July 1, 2024, acute care hospitals who are required through a CMS program to participate in NHSN are also required to join The Joint Commission NHSN Group. 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.

eCQMs and Chart-abstracted measures are submitted for all four (4) quarters unless otherwise noted.
In order to meet ORYX requirements, submitted measures must be applicable to patient population/services offered.

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

[HAP Large] Hospitals with ≥ 26 Licensed beds OR ≥ 50,000 Outpatient visits AND Provide Obstetrical Services
REQUIRED MEASURES: The following four measures are required:
PC-06 (eCQM or chart-abstracted): Unexpected Complications in Term Newborns NOTE: May be submitted as either Chart-abstracted Measure or eCQM; if submitted as eCQM, it counts towards the eCQM minimum requirement. If submitting as eCQM, PC attestation is required.
ePC-02 (eCQM) Cesarean Birth
ePC-07 (eCQM) Severe Obstetric Complications (there is no corresponding chart-abstracted measure)
Safe Use of Opioids (eCQM)
REQUIRED: In addition to the above required measures, your hospital must also submit a minimum of three (3) additional eCQMs applicable to patient population/services from those listed below:
eGMCS (eCQM) Global Malnutrition Composite Score (NEW)
eHH-01(eCQM) Hospital Harm—Severe Hypoglycemia Measure
eHH-02 (eCQM) Hospital Harm—Severe Hyperglycemia Measure
eHH-03 (eCQM) Hospital Harm—Opioid Related Adverse Events (NEW)
eOP-40 (eCQM) ST-Segment Elevation Myocardial Infarction NOTE: 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.
ePC-01 (eCQM) Elective Delivery
ePC-05 (eCQM) Exclusive Human Milk Feeding
ePC-06 (eCQM) Unexpected Complications in Term Newborns
eSTK-2 (eCQM)Discharged on Antithrombotic Therapy
eSTK-3 (eCQM) Anticoagulation Therapy Atrial Fibrillation/Flutter
eSTK-5 (eCQM) Antithrombotic Therapy by End of Hospital Day 2
eVTE-1 (eCQM) Venous Thromboembolism Prophylaxis
eVTE-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.
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 (NEW) 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 (NEW) 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
VTE-6 (CAM) Hospital Acquired Potentially-Preventable VTE

The Joint Commission

[HAP Large] Acute Care Hospitals with Obstetrical Services (2024)

CY2024 ORYX Requirements for [HAP Large] Acute Care Hospitals with Obstetrical Services

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

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

NOTE: May be submitted as either Chart-abstracted Measure or eCQM; if submitted as eCQM, it counts towards the eCQM minimum requirement. If submitting as eCQM, PC attestation is required.

NOTE: 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.

NOTE: IMM-2 is a seasonal measure; only 1Q and 4Q data are submitted

NOTE: SDOH measures are not submitted quarterly, but are instead submitted annually in alignment with the 4Q CAM submission deadline.

NOTE: SDOH measures are not submitted quarterly, but are instead submitted annually in alignment with the 4Q CAM submission deadline.