Dear Colleague: 

The Joint Commission updated the CY2025 ORYX® Performance Measure reporting requirements. These updates affect reporting requirements for Joint Commission–accredited hospitals and critical access hospitals effective January 1, 2025.  

Please review the detailed list of all requirements and measures by organization type for CY2025 via The Joint Commission’s ORYX Performance Measurement Reporting page. 

Key 2025 updates include the following: 

1. New submission requirement for small hospitals (< 26 licensed beds and <50,000 outpatient visits) and critical access hospitals: 

o   Submit at least one eCQM for the entire calendar year, plus two additional measures (these may be chart-abstracted measures [CAM], eCQMs, or a combination of both) applicable to their patient population/services offered, totaling three measures. The submission of the Safe Use of Opioids – Concurrent Prescribing eCQM is highly encouraged. 

2. The Joint Commission has added the following electronic clinical quality measures (eCQMs) as optional reporting measures available to meet reporting requirements: 

o   Hospital Harm - Pressure Injury (HH-PI) 

o   Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Inpatient) (IP-ExRad) 

o   Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Outpatient) (OP-ExRad) 

3. The following two outpatient eCQMs are included as optional measures and are aligned with the US Centers for Medicare & Medicaid Services’ implementation approach, which allows for data submission of less than a full year for new outpatient eCQMs:  

o   ST-Segment Elevation Myocardial Infarction (STEMI) (OP-40) – submit a minimum of two self-selected quarters; this will count as a complete measure / towards meeting the eCQM requirement 

o   Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (OP-ExRad) – submit a minimum of one self-selected quarter; this will count as a complete measure / towards meeting the eCQM requirement 

4. The following chart-abstracted measure will be retired as of January 1, 2025: 

o   VTE-6: Hospital Acquired Potentially-Preventable Venous Thromboembolism 

Resources: 

The ORYX Performance Measurement Timeline for data submission is available via the DDSP “Need Help?” and ORYX FAQs; quick link:  

https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/71008257  

The ORYX FAQs are available via the “Measurement” section of The Joint Commission website; quick link: https://www.jointcommission.org/measurement/oryx-faqs/  

Chart-abstracted Specifications for Joint Commission measures are available on Specification section of The Joint Commission’s ORYX Performance Measurement page. 

eCQM Specifications are available on the Electronic Clinical Quality Improvement (eCQI) Resource Center website. 

REMINDER: Pioneers in Quality Webinar 2025 Joint Commission ORYX® Performance Measurement Requirements for Hospitals, Live Webinar October 24, 2024: https://goto.webcasts.com/starthere.jsp?ei=1690093&tp_key=ea79902124 

Questions regarding these updates and requirements may be directed to the ORYX Help Inbox. Please include your HCO ID # in the subject line of all inquiries.  

Thank You  

Dear Colleague: 

This communication is to correct an error on Slide #89 from the 9/10/2024 Office Hours. The slide stated that eCQM patient-level data submitted to the DDSP will be removed six months after the close of the eCQM submission period. However, sub-bullet #3 incorrectly stated that “QI page graphs and results table view… will continue to display.” The correct information is that the data associated with the graphs on the QI page and the results table view will not be available after the patient-level data has been removed from the DDSP. 

Historical HCO-level aggregate eCQM data is included in the DDSP’s Data Submission Report. This report is available on the Home page of the DDSP and documents the hospital’s data submission for the year. 

Hospitals wishing to retain the DDSP-generated eCQM patient-level data results must download them from the DDSP Quality Improvement page before six months after the close of the eCQM submission period. The patient-level results can be downloaded using the “Review Patient Results” button on the Quality Improvement page. For CY2023 data, the deadline to download is September 30, 2024. 

Corrected 9/10/2024 Office Hour Slide #89: 
Slide #89 Office Hours (corrected)
Thank you 

Dear Colleague: 

The Specifications Manual for Joint Commission National Quality Measures, version 2025A (applicable starting with 1/1/2025 encounters) and associated Release Notes have been posted to the Wiki Joint Commission Specifications Manual website and the Joint Commission website.
 
The 2025A Specifications Manual contains the following changes:

• ACHF-01 and all optional outpatient measures are removed for Advanced Certification Heart Failure Centers. These changes resulted from feedback from The Joint Commission’s public comment period, a technical advisory panel, the American Heart Association (AHA), the American College of Cardiology (ACC), and the Heart Failure Society of America (HFSA)- 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

• The use of Gestational Age code tables in PC-01 and PC-02 has been removed from the 2025A manual since the intent of the measures is to capture the gestational age at time of delivery.

• The PDF version of the manual is not being published due to 508 Compliance issues.  As an alternative option, users can PDF each section of the web version by clicking on the ellipsis in the browser menu, then click Print and select Adobe PDF.

See Release Notes for details on all of the changes to this version of the Specifications Manual.

Please share this information with relevant staff in your organization and if applicable with your vendor.

Questions?
Please contact https://manual.jointcommission.org  
Thank you 

Dear Colleague: 

This is a reminder for those organizations required or electing to submit 2Q2024 chart-abstracted data to The Joint Commission. Please note this email is sent to all organizations regardless of organization’s current submission status within The Joint Commission Direct Data Submission Platform (DDSP).

The Joint Commission deadline for submitting 2Q2024 chart-abstracted data to the DDSP is September 30, 2024 at 11:59 PM Central Time. We strongly encourage organizations to submit their data well in advance of the deadline.

CY2024 ORYX Performance Measurement Timeline

• 1Q 2024 (Jan, Feb, Mar) Chart-abstracted measures: DDSP opens February 1, 2024 and data must be entered by June 30, 2024

• 2Q 2024 (Apr, May, Jun) Chart-abstracted measures: DDSP opens May 1, 2024 and data must be entered by September 30, 2024

• 3Q 2024 (Jul, Aug, Sep) Chart-abstracted measures: DDSP opens August 1, 2024 and data must be entered by December 31, 2024

• 4Q 2024 (Oct, Nov, Dec) Chart-abstracted measures: DDSP opens November 1, 2024 and data must be entered by March 31, 2025

• CY2024 eCQMs: DDSP opens August 5, 2024; Transmission period to submit data opens January 1, 2025, and data must be submitted by March 17, 2025

The ORYX Performance Measurement Timeline for CY2024 data submission is available via the DDSP “Need Help?” and ORYX FAQs; quick link: 
https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/71008257  

Deadline for retransmission of 3Q2023 CAM Data
If your organization identified incorrectly entered or incorrectly omitted chart-abstracted data for 3Q2023, the deadline to correct this is September 30, 2024 at 11:59 PM Central Time. Therewill be no opportunity to resolve 3Q2023 CAM data beyond this date.

Information on Retransmission is available via the DDSP “Need Help?” and ORYX FAQs; quick link: 
https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/141295632

CY2024 ORYX Performance Measurement Requirements
Requirements for CY2024 are available on our website:
https://www.jointcommission.org/measurement/reporting/accreditation-oryx/

Questions
If you need assistance or have questions with any portion of the DDSP, please submit a support ticket via the DDSP “Need Help?” button.

If you have non-DDSP questions, please contact hcooryx@jointcommission.org and include your HCO ID in the subject line.  
Thank you 

The Joint Commission will be hosting office hours for the Direct Data Submission Platform (DDSP) on Tuesday, September 10, 2024 from 11am - 12:00pm (Central Time). The Direct Data Submission Platform (DDSP) is used for submission of required ORYX Performance Measurement data.  

Office hours are a webinar-based format.  The content of the webinar for office hours includes tips for successful use of the platform and data submission. The webinar is staffed by The Joint Commission staff to answer questions for HCOs. Attendees can ask questions via the Ask a Question feature. 
  
Please register for the September 10th session using this link: 
https://goto.webcasts.com/starthere.jsp?ei=1652170&tp_key=54b581baec

Each participant should register individually, as the sign on link provided after registration is specific to each registrant. Please forward this link to any staff or consultants participating in ORYX Performance Measurement and/or data submission to the DDSP who may benefit from the content in these webinars.   

Office hours are recorded. The recording will be available via the same registration link and recordings are also available on the DDSP via the “Need Help?” link, “Education Learning Resources”.

The proposed agenda for the September 10th webinar is:

• Overview of CY2024 platform updates

We recommend users new to ORYX and/or the DDSP review the available platform demonstration videos and supporting documentation in advance of Office Hours. These are available via the DDSP “Need Help?” / Learning & Resources link within the platform and available here:
DDSP Platform Demo Videos

Questions Regarding Office Hours   
Contact hcooryx@jointcommission.org and in the email subject line include DDS Participant and HCO ID. 
  
Thank you