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

[HAP Large] Hospitals with ≥ 26 Licensed beds OR ≥ 50,000 Outpatient visits AND Provide Obstetrical Services

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) (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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