Facts about ORYX for Hospitals

  • The Joint Commission’s ORYX initiative integrates performance measurement data into the accreditation process.
  • ORYX measurement requirements support Joint Commission-accredited organizations in their quality improvement efforts.
  • The Joint Commission continues to align measures as closely as possible with the Centers for Medicare & Medicaid Services (CMS).

ORYX chart-abstracted data are publicly reported on The Joint Commission’s Quality Check® website. At this time, eCQM data is not being publicly reported by The Joint Commission.

The following sections provide the ORYX reporting requirements for the respective year and links to important resources and supporting material.


For CY2021 discharges, Accredited hospitals submit both electronic clinical quality measure (eCQM) and chart-abstracted measure data via The Joint Commission’s Direct Data Submission Platform (DDSP). eCQM data is submitted to The Joint Commission on a yearly basis. Chart Abstracted measure data is submitted as monthly aggregate data on a quarterly basis.

  • Acute Care Hospitals having Licensed Beds >= 26 OR Outpatient Visits >= 50,000 and 300+ live births annually submit four chart-abstracted measures (PC-01, PC-02, PC-05 and PC-06), and select a minimum of 4 eCQMs, reporting the same eCQMs for two self-selected quarters. There are twelve eCQMs available.
  • Acute Care Hospitals having Licensed Beds >= 26 OR Outpatient Visits >= 50,000 and 1-299 live births annually submit one chart-abstracted measures (PC-01), and select a minimum of 4 eCQMs, reporting the same eCQMs for two self-selected quarters. There are twelve eCQMs available.
  • Acute Care Hospitals having Licensed Beds >= 26 OR Outpatient Visits >= 50,000 and do not provide obstetrical service do not submit chart-abstracted measures, and select a minimum of 4 eCQMs, reporting the same eCQMs for two self-selected quarters. There are twelve eCQMs available.
  • Hospitals having Licensed Beds <26 AND Outpatient Visits < 50,000 (small hospitals), are required to submit any combination of three (3) eCQMs and/or chart-abstracted measures applicable to patient population/services offered.
  • Critical Access Hospitals (CAHs) are required to submit any combination of three (3) eCQMs and/or chart-abstracted measures applicable to patient population/services offered.
  • Freestanding Psychiatric Hospitals continue to report on the four required Hospital-Based Inpatient Psychiatric Services (HBIPS) measures (HBIPS-1, HBIPS-2, HBIPS-3, and HBIPS-5).
  • Free-standing Children’s Hospitals, Long Term Acute Care Hospitals (LTACHs), Inpatient Rehabilitation Facilities (IRFs) and HCOs participating in CMS PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) program reporting requirements remain suspended.
  • The Joint Commission has eliminated “self-reporting” of ORYX data. Hospitals that self-reported performance measurement data in the past are now expected to submit their data, starting CY2021, to the Direct Data Submission Platform (DDSP).

Supporting Material:

For CY2020 discharges, Accredited hospitals now submit both electronic clinical quality measure (eCQM) and chart-abstracted measure data via The Joint Commission’s Direct Data Submission Platform (DDSP).

  • eCQM data is submitted to The Joint Commission on a yearly basis.
  • Chart Abstracted measure data is submitted as monthly aggregate data on a quarterly basis.

Hospital Accreditation program with average daily census (ADC) >10

  • Report a minimum of four (of 10 available) eCQMs for one self-selected calendar quarter via DDSP.
  • Hospitals providing obstetrical services report via DDSP on one required chart-abstracted measure — perinatal care (PC) measure PC-01.
  • Hospitals with at least 300 live births per year — in addition to PC-01 — report via DDSP on all chart-abstracted PC measures (PC-02, PC-05, and PC-06). 
    Note: Effective 1/1/2020 PC-03 and PC-04 have been retired for accreditation and certification purposes.

Critical access hospitals, small hospitals with ACD <10 inpatients, and ORYX®-designated specialty program

  • Report on a choice of three available measures (chart-abstracted or eCQMs
  • These hospitals remain exempt from requirement to submit data to The Joint Commission. If data are not submitted, the organization is required to make data reports available for review by surveyors during on-site surveys.

Freestanding Psychiatric Hospitals Accreditation program

  • Report via DDSP on the four required hospital-based inpatient psychiatric services (HBIPS) measures (HBIPS-1, HBIPS-2, HBIPS-3, and HBIPS-5).

Hospital Accreditation programs for which ORYX performance measure reporting requirements continue to be suspended

  • Suspension of requirements continues for freestanding children’s hospitals, long-term acute care hospitals and inpatient rehabilitation facilities.

Supporting Material:

For CY2019 discharges, Accredited hospitals submit

  • Electronic clinical quality measure (eCQM) via The Joint Commission’s Direct Data Submission Platform (DDSP). eCQM data is submitted to The Joint Commission on a yearly basis.
  • Chart-abstracted measure data using an ORYX vendor. Chart Abstracted measure data is submitted on a quarterly basis.

Hospital Accreditation program with average daily census (ADC) >10

  • Report a minimum of four (of 13 available) eCQMs for one self-selected calendar quarter via DDSP.
  • Hospitals providing obstetrical services report via DDSP on one required chart-abstracted measure — perinatal care (PC) measure PC-01.
  • Hospitals with at least 300 live births per year — in addition to PC-01 — report via DDSP on all chart-abstracted PC measures (PC-02, PC-03, PC-04, PC-05, and PC-06).

Critical access hospitals, small hospitals with ACD <10 inpatients, and ORYX-designated specialty program

  • Report on a choice of three available measures (chart-abstracted or eCQMs).
  • These hospitals remain exempt from requirement to submit data to The Joint Commission. If data are not submitted, the organization is required to make data reports available for review by surveyors during on-site surveys.

Freestanding Psychiatric Hospitals Accreditation program

  • Report via DDSP on the four required hospital-based inpatient psychiatric services (HBIPS) measures (HBIPS-1, HBIPS-2, HBIPS-3, and HBIPS-5).

Hospital Accreditation programs for which ORYX performance measure reporting requirements continue to be suspended

  • Suspension of requirements continues for freestanding children’s hospitals, long-term acute care hospitals and inpatient rehabilitation facilities.

Supporting Material