The Joint Commission

[CAH] Critical Access Hospitals (2022)


CY2022 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.


  • eCQMs are submitted for three (3) quarters.

  • Chart-abstracted measures are submitted for 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)

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.

AVAILABLE eCQMs:

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

eOPI-1 (eCQM) Safe Use of Opioids

ePC-01 (eCQM) Elective Delivery

ePC-02 (eCQM): Cesarean Birth

ePC-05 (eCQM) Exclusive Breast 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

eSTK-6 (eCQM) Discharged on Statin Medication

eVTE-1 (eCQM) Venous Thromboembolism Prophylaxis

eVTE-2 (eCQM) ICU Venous Thromboembolism Prophylaxis

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-1 (CAM) Admission Screening

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

PC-01 (CAM): Elective Delivery

PC-02 (CAM): Cesarean Birth

ePC-06 (CAM): Exclusive Human Milk Feeding

PC-06

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