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[HAP Large] Acute Care Hospitals with Obstetrical Services (2023)

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Last updated: Jul 23, 2024
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CY2023 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.

  • 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 perinatal care measure is required for organizations with 1-299 live births annually.

NOTE: PC measures 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-01 or PC-01 (eCQM or chart-abstracted): Elective Delivery

REQUIRED MEASURES: The following four perinatal care measures are required for organizations with 300 or more live births annually.

NOTE: PC measures 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-01 or PC-01 (eCQM or chart-abstracted): Elective Delivery

ePC-02 or PC-02 (eCQM or chart-abstracted): Cesarean Birth

ePC-05 or PC-05 (eCQM or chart-abstracted): Exclusive Human Milk Feeding

ePC-06 or PC-06 (eCQM or chart-abstracted): Unexpected Complications in Term Newborns

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

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

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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