The Joint Commission

[HAP Large] Acute Care Hospitals that do not provide Obstetrical Services (2023)

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Last updated: Oct 08, 2024 by Patty Craig
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CY2023 ORYX Requirements for [HAP Large] Acute Care Hospitals that DO NOT provide 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.

  • 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 DO NOT Provide Obstetrical Services

[HAP Large] Hospitals with ≥ 26 Licensed beds OR ≥ 50,000 Outpatient visits AND DO NOT Provide Obstetrical Services

AVAILABLE: Your hospital must submit a minimum of four(4) eCQMs from those listed below:

eED-2 (eCQM) Admit Decision Time to ED Departure-Admit

eOPI-1 (eCQM) Safe Use of Opioids

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

eSTK-6 (eCQM) Discharged on Statin Medication

eVTE-1 (eCQM) Venous Thromboembolism Prophylaxis

eVTE-2 (eCQM) ICU Venous Thromboembolism Prophylaxis

eHH-01(eCQM) Hospital Harm—Severe Hypoglycemia Measure

eHH-02 (eCQM) Hospital Harm—Severe Hyperglycemia Measure

eOP-40 (eCQM) ST-Segment Elevation Myocardial Infarction

OPTIONAL Chart-Abstracted Measures

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

HBIPS-5 (CAM) Antipsychotic Medications at Discharge

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

SUB-2 (CAM) Alcohol Use Brief Intervention

SUB-3 (CAM) Alcohol & Drug Use Treatment at Discharge

TOB-2 (CAM) Tobacco Use Treatment

TOB-3 (CAM) Tobacco Use Treatment at Discharge

VTE-6 (CAM) Hospital Acquired Potentially-Preventable VTE 

 

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