The Joint Commission

[HAP Small] Acute Care Hospitals (2023)

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Last updated: Oct 08, 2024 by Patty Craig
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CY2023 ORYX Requirements for [HAP Small] Acute Care Hospitals

How are [HAP Small] 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 Small are defined as <26 Licensed beds AND<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.

  • eCQMs and Chart-abstracted measures are submitted for all four (4) quarters unless otherwise noted.

  • HAP Small Acute Care Hospitals are not required to submit PC measures but may do so if they choose if obstetrical services are provided.

  • In order to meet ORYX requirements, submitted measures must be applicable to patient population/services offered.

[HAP Small] Hospitals with <26 Licensed beds AND < 50,000 Outpatient visits

[HAP Small] Hospitals with <26 Licensed beds AND < 50,000 Outpatient visits

REQUIRED: Submit any three (3) measures (chart-abstracted measures and/or eCQMs) applicable to patient population/ services offered.

  • May elect to submit additional measures based on patient population / services offered.

  • Not required to submit PC measures but may do so if they choose.

AVAILABLE eCQMs:

eED-2 (eCQM): Admit Decision Time to ED Departure-Admit

eOPI-1 (eCQM): Safe Use of Opioids

ePC-01 (eCQM): Elective Delivery

ePC-02 (eCQM): Cesarean Birth

ePC-05 (eCQM): Exclusive Breast Milk Feeding

ePC-06 (eCQM): Unexpected Complications in Term Newborns

ePC-07 (eCQM): Severe Obstetric Complications

eSTK-2 (eCQM): Discharged on Antithrombotic Therapy

eSTK-3 (eCQM): Anticoagulation Therapy Atrial Fibrillation/Flutter

eSTK-5 (eCQM): Antithrombotic Therapy by End of Hospital Day 2

eSTK-6 (eCQM): Discharged on Statin Medication

eVTE-1 (eCQM): Venous Thromboembolism Prophylaxis

eVTE-2 (eCQM): ICU Venous Thromboembolism Prophylaxis

eHH-01(eCQM): Hospital Harm—Severe Hypoglycemia Measure

eHH-02 (eCQM): Hospital Harm—Severe Hyperglycemia Measure

eOP-40 (eCQM): ST-Segment Elevation Myocardial Infarction

OPTIONAL Chart-Abstracted Measures

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

HBIPS-5 (CAM): Antipsychotic Medications at Discharge

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-06 (CAM): Exclusive Human Milk Feeding

PC-06 (CAM): Unexpected Complications in Term Newborns

SUB-2 (CAM): Alcohol Use Brief Intervention

SUB-3 (CAM): Alcohol & Drug Use Treatment at Discharge

TOB-2 (CAM): Tobacco Use Treatment

TOB-3 (CAM): Tobacco Use Treatment at Discharge

VTE-6 (CAM): Hospital Acquired Potentially-Preventable VTE 

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