The Joint Commission

2025 ORYX Performance Measurement Reporting Requirements

Owned by Kelly C
Last updated: Oct 10, 2024
2 min read

 NEW for 2025:

  • Effective CY2025, The Joint Commission has added the following eCQMs as available optional measures towards meeting ORYX requirements:

    • eCQM: Hospital Harm - Pressure Injury (HH-PI)

    • eCQM: Excessive Radiation Dose or Inadequate Image Quality for Computed Tomography (CT) in Adults (Inpatient) (IP-ExRad)

    • eCQM: Excessive Radiation Dose or Inadequate Image Quality for Computed Tomography (CT) in Adults (Outpatient) (OP-ExRad)

  • Effective CY2025, The Joint Commission has retired the following chart-abstracted measure:

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

  • Effective CY2025, Small hospitals are required to submit a minimum of one (1) eCQM for the entire calendar year, plus two additional measures (Chart-abstracted, eCQM, or combination of both) applicable to their patient population and services offered.

  • Effective CY2025, Critical Access Hospitals are required to submit a minimum of one (1) eCQM for the entire calendar year, plus two additional measures (Chart-abstracted, eCQM, or combination of both) applicable to their patient population and services offered.

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 

Refer to the Timeline for information regarding data submission deadlines: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/71008257

ORYX REQUIREMENTS for 2025:

[HAP Large] Acute Care Hospitals that Provide Obstetrical Services
HAP Large are defined as ≥26 Licensed beds OR ≥ 50,000 Outpatient visits

[HAP Large] Acute Care Hospitals that Provide Obstetrical Services
HAP Large are defined as ≥26 Licensed beds OR ≥ 50,000 Outpatient visits

[HAP Large] Acute Care Hospitals that DO NOT provide Obstetrical Services
HAP Large are defined as ≥26 Licensed beds OR ≥ 50,000 Outpatient visits

[HAP Large] Acute Care Hospitals that DO NOT provide Obstetrical Services
HAP Large are defined as ≥26 Licensed beds OR ≥ 50,000 Outpatient visits

[HAP Small] Acute Care Hospitals
HAP Small are defined as <26 Licensed beds AND <50,000 Outpatient visits

[HAP Small] Acute Care Hospitals
HAP Small are defined as <26 Licensed beds AND <50,000 Outpatient visits

[CAH] Critical Access Hospitals
[CAH] Critical Access Hospitals adhere to the CAH standards manual, and are a specific designation by the state as a critical access hospital in a rural area.

[CAH] Critical Access Hospitals
[CAH] Critical Access Hospitals adhere to the CAH standards manual, and are a specific designation by the state as a critical access hospital in a rural area.

[HAP PSYCH] Freestanding Psychiatric Hospital
HAP PSYCH are defined as a "Freestanding" Psychiatric Facility licensed and separately accredited as freestanding psychiatric hospital; it is not a unit within a hospital that is surveyed at the same time as the hospitals and shares an HCO ID #.

[HAP PSYCH] Freestanding Psychiatric Hospital
HAP PSYCH are defined as a "Freestanding" Psychiatric Facility licensed and separately accredited as freestanding psychiatric hospital; it is not a unit within a hospital that is surveyed at the same time as the hospitals and shares an HCO ID #.

[ALC] Assisted Living Community
ALCs adhere to the ALC standards manual.

[ALC] Assisted Living Community
ALCs adhere to the ALC standards manual.

Suspended Accreditation Programs
Suspended organizations may submit ORYX Performance Measures to The Joint Commission via the DDSP if they choose.

Suspended Accreditation Programs
Suspended organizations may submit ORYX Performance Measures to The Joint Commission via the DDSP if they choose.

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

 

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