The Joint Commission
[HAP Small] Acute Care Hospitals (2024)
CY2024 ORYX Requirements for [HAP Small] Acute Care Hospitals
How are [HAP Small] 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 Small are defined as <26 Licensed beds AND <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.
See also: DDSP General: Verifying Data Submission & ORYX Requirements https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/106496001
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.
See Also: 12. NHSN Group for The Joint Commission https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/143720449
eCQMs and Chart-abstracted measures are submitted for all four (4) quarters unless otherwise noted.
HAP Small Acute Care Hospitals are not required to submit PC measures but may do so if they choose if obstetrical services are provided.
In order to meet ORYX requirements, submitted measures must be applicable to patient population/services offered.
HAP Small] Hospitals with <26 Licensed beds AND < 50,000 Outpatient visits |
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REQUIRED: Submit any three (3) measures (chart-abstracted measures and/or eCQMs) applicable to patient population/ services offered.
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AVAILABLE eCQMs: |
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) |
Safe Use of Opioids (eCQM) |
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-02 (eCQM) Cesarean Birth |
ePC-05 (eCQM) Exclusive Human Milk Feeding |
ePC-06 (eCQM) Unexpected Complications in Term Newborns |
ePC-07 (eCQM) Severe Obstetric Complications |
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 |
AVAILABLE Chart-abstracted measures (CAM); NOTE: Any chart-abstracted measure(s) submitted 1Q2024 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 |
See also: ORYX FAQs Measure Requirements: By Organization Type: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/37486764
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