The Joint Commission
[HAP Large] Acute Care Hospitals with Obstetrical Services (2025)
CY2025 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.
See also: DDSP General: Verifying Data Submission & ORYX Requirements DDSP General: Verifying Data Submission & ORYX Requirements
REMINDER: 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 12. NHSN Group for The Joint Commission
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 and services offered.
[HAP Large] Hospitals with ≥ 26 Licensed beds OR ≥ 50,000 Outpatient visits AND Provide Obstetrical Services |
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REQUIRED MEASURES: The following four measures are required: |
PC-06 (eCQM or chart-abstracted): Unexpected Complications in Term Newborns NOTE: 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. |
PC-02 (eCQM) Cesarean Birth |
PC-07 (eCQM) Severe Obstetric Complications (there is no corresponding chart-abstracted measure) |
Safe Use of Opioids (eCQM) Safe Use of Opioids - Concurrent Prescribing |
REQUIRED: In addition to the above required measures, your hospital must also submit a minimum of three (3) additional eCQMs applicable to patient population/services from those listed below: |
IP-ExRad (eCQM) Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Inpatient)Â (NEW) |
OP-ExRad (eCQM) Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Outpatient) (NEW) NOTE: If OP-ExRad is reported, one (1) self-selected quarter is required and will count as a complete measure / towards meeting the eCQM requirement |
HH-PI (eCQM) Hospital Harm - Pressure Injury (NEW) |
GMCS (eCQM) Global Malnutrition Composite Score |
HH-HYPO (eCQM) Hospital Harm—Severe Hypoglycemia Measure |
HH-HYPER (eCQM) Hospital Harm—Severe Hyperglycemia Measure |
HH-ORAE (eCQM) Hospital Harm—Opioid Related Adverse Events |
OP-40 (eCQM) ST-Segment Elevation Myocardial Infarction (STEMI) NOTE: If OP-40 is reported, two (2) self-selected quarter are required and will count as a complete measure / towards meeting the eCQM requirement. |
PC-01 (eCQM) Elective Delivery |
PC-05 (eCQM) Exclusive Human Milk Feeding |
PC-06 (eCQM) Unexpected Complications in Term Newborns |
STK-2 (eCQM) Discharged on Antithrombotic Therapy |
STK-3 (eCQM) Anticoagulation Therapy Atrial Fibrillation/Flutter |
STK-5 (eCQM) Antithrombotic Therapy by End of Hospital Day 2 |
VTE-1 (eCQM) Venous Thromboembolism Prophylaxis |
VTE-2 (eCQM) ICU Venous Thromboembolism Prophylaxis |
OPTIONAL Chart-abstracted measures (CAM); hospitals may elected to submit any of the below measures if they choose. NOTE: Any chart-abstracted measure(s) submitted the first quarter of the calendar year 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 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 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 |
See also: ORYX FAQs Measure Requirements: By Organization Type: 5. Measure Requirements: By Organization Type
 Return to: ORYX Performance Measurement Reporting Requirements Main Page:
https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/403472385
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