[CAH] Critical Access Hospitals (2024)

CY2024 ORYX Requirements for [CAH] Critical Access Hospitals

How are [CAH] Critical Access Hospitals defined as it relates to ORYX Requirements?

[CAH] Critical Access Hospitals adhere to the CAH standards manual, and are a specific designation by the state as a critical access hospital in a rural area. For more information on CAH eligibility, contact your Joint Commission Account Executive and/or see also the accreditation health care settings on The Joint Commission Website.

For The Joint Commission, ORYX performance measurement requirements are specifically applicable to organizations accredited under the Critical Access Hospital (CAH) manual.

NOTE: In addition to required ORYX performance measurement data submission to The Joint Commission via the Direct Data Submission Platform, effective July 1, 2024, critical access hospitals may elect to join The Joint Commission NHSN Group if they choose. 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.

Critical Access Hospitals (CAH)

REQUIRED: Submit any three (3) measures (chart-abstracted measures and/or eCQMs) applicable to patient population/ services offered.

May elect to submit additional measures based on patient population / services offered.
Not required to submit PC measures but may do so if they choose.
Participation in the Joint Commission NHSN Group is optional for CAHs.

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