[HAP Large] Acute Care Hospitals that do not provide Obstetrical Services (2025)

CY2025 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.

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.

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
REQUIRED MEASURES: The following one measure is required:
Safe Use of Opioids (eCQM) Safe Use of Opioids - Concurrent Prescribing
REQUIRED: In addition to the above required measure, 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.
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
AVAILABLE Chart-abstracted measures (CAM); hospitals may elected to submit any of the below measures if they choose. NOTE: Any chart-abstracted measure(s) submitted 1Q2024 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
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

Return to: ORYX Performance Measurement Reporting Requirements Main Page:
https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/403472385

The Joint Commission

[HAP Large] Acute Care Hospitals that do not provide Obstetrical Services (2025)

CY2025 ORYX Requirements for [HAP Large] Acute Care Hospitals that DO NOT provide Obstetrical Services

[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

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

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.

NOTE: IMM-2 is a seasonal measure; only 1Q and 4Q data are submitted

NOTE: SDOH measures are not submitted quarterly, but are instead submitted annually in alignment with the 4Q CAM submission deadline.

NOTE: SDOH measures are not submitted quarterly, but are instead submitted annually in alignment with the 4Q CAM submission deadline.