The Joint Commission’s ORYX® initiative integrates performance measurement data into the accreditation process. ORYX measurement requirements are intended to support Joint Commission-accredited organizations in their quality improvement efforts. Performance measures are essential to the credibility of any modern evaluation activity for health care organizations. ORYX chart-abstracted data are publicly reported on The Joint Commission website at Quality Check®, www.qualitycheck.org. The public availability of performance measure data permits user comparisons of hospital performance on individual measures reported at the state and national levels.
2017 ORYX performance measure reporting requirements
For 2017, The Joint Commission has eliminated the measure set reporting requirement. Measure selection and reporting is by individual measure. Joint Commission-accredited hospitals with an average daily census of more than 10 inpatients will report, at a minimum, on five required chart-abstracted measures, which should include ED-1 and ED-2, IMM-2, VTE-6, and PC-01, and a choice of six of 13 available electronic clinical quality measures (eCQMs). Hospitals with at least 300 live births per year also will be required to report on all of the chart-abstracted perinatal care measures, which should include PC-02, 03, 04, and 05. Monthly data on all chart-abstracted measures will continue to be reported to The Joint Commission on a quarterly basis using a Joint Commission-listed vendor.
Hospitals will have two options for reporting eCQM data to The Joint Commission: 1) through a Joint Commission listed vendor that supports eCQM data collection and reporting, or 2) through a secure extranet connection that allows hospitals to directly submit their 2017 QRDA Category 1 files. Direct submission of eCQM data will be available in time for the March 15, 2018, eCQM data submission deadline. For hospitals submitting data directly, there will be transmission fees matching those charged to ORYX vendors. The Joint Commission is moving to a flat fee billing model for 2017 eCQM data submissions, charging the eCQM vendor or hospital directly submitting $300 per hospital per year for all eCQMs transmitted. In selecting eCQMs, hospitals must indicate the listed ORYX eCQM vendor, or for those directly submitting, choose Direct Submission Vendor (0100-04).
More information can be found on the Performance Measurement webpage, including:
- • 2017 ORYX Performance Measure Reporting Requirements
- • Joint Commission Measures Effective Jan. 1, 2017
- • Frequently Asked Questions About 2017 ORYX Performance Measure Reporting Requirements
Requirements for small hospitals
Hospitals with an average daily census of 10 or fewer inpatients (i.e., “small hospitals”) are required to report on a minimum of six measures. The six measures may be selected from among all the available chart-abstracted measures and eCQMs based upon the patient populations served and services provided by the hospital. The selections may include all chart-abstracted measures, all eCQMs, or a combination of chart-abstracted measures and eCQMs. Small hospitals are exempt from the requirement to transmit data to The Joint Commission, however, they may elect to do so. If data are not transmitted, the organization will be required to make data reports available for review by, and share data conclusions with, surveyors during on-site surveys.
Requirements for critical access hospitals
Critical access hospitals are required to report on a minimum of six measures. The six measures may be selected from among all the available chart-abstracted measures and eCQMs based upon the patient populations served and services provided by the hospital. The selections may include all chart-abstracted measures, all eCQMs, or a combination of chart-abstracted measures and eCQMs. Critical access hospitals are exempt from the requirement to transmit data to The Joint Commission, however, they may elected to do so. If data are not transmitted, the organization will be required to make data reports available for review by, and share data conclusions with, surveyors during on-site surveys.
Requirements for freestanding psychiatric hospitals
Psychiatric hospitals that are “freestanding” facilities separately accredited by The Joint Commission (i.e., they are not surveyed and accredited as a site under the accreditation of the main Joint Commission-accredited hospital), are required to collect and transmit data to The Joint Commission for the hospital-based inpatient psychiatric services (HBIPS) measures only. However, they may elect to report on additional measures relevant to their inpatient population. Acute care hospitals with inpatient psychiatric units are not required to report on the HBIPS measures, however, they may elect to collect and submit data to The Joint Commission on any of the HBIPS measures to meet or exceed their basic ORYX measure reporting requirements. For detailed information on the HBIPS measures, see the Specifications Manual for Joint Commission National Quality Core Measures.
Requirements for freestanding children’s hospitals
ORYX performance measure reporting requirements for children’s hospitals that are “freestanding” facilities separately accredited by The Joint Commission (i.e., they are not surveyed and accredited as a site under the accreditation of the main Joint Commission-accredited hospital), were suspended for 2016 and remain suspended for 2017. Accredited freestanding children’s hospitals are expected to meet performance measurement and improvement requirements through ongoing compliance with the Performance Improvement (PI) standards.
Requirements for long term acute care hospitals (LTACHs) and inpatient rehabilitation facilities (IRFs)
The Joint Commission has suspended ORYX performance measure reporting requirements for accredited long term acute care hospitals (LTACHs) and inpatient rehabilitation facilities (IRFs) only. Accredited LTACHs and IRFs are expected to meet performance measurement and improvement requirements through ongoing compliance with the Performance Improvement (PI) standards.
Read more about ORYX® for hospitals
• Performance Measurement webpage
• The Specifications Manual for National Hospital Inpatient Quality Measures
• The Specifications Manual for Joint Commission National Quality Core Measures
• Hospital Outpatient Quality Reporting Specifications Manual
Read more about ORYX® for hospitals
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