Measure Requirements: By Hospital Type
3 JAN 2022 last update
Section 5: Measure Requirements: By Hospital Type
5.1: We are a Small / Critical Access hospital and self-report our data. Are we required to use the DDSP for CY2022?
Yes; The option to self-report (collecting data internally and making it available at the time of survey) has been removed. Effective CY2021, all hospitals with ORYX requirements are required to submit data via the DDSP. Requirements are posted on our external website under the supporting materials section of: https://www.jointcommission.org/measurement/resources/
5.2: Do Small hospitals and CAHs need to report eCQMs?
Small hospitals and CAHs are not required to submit eCQMs but may do so if they choose in order to meet their minimum reporting requirements. Those electing to submit eCQMs in order to meet their minimum reporting requirements must submit three quarters of data for any eCQM measure they choose to submit.
5.3: Do Small hospitals and CAHs need to report on the Perinatal Care (PC) measures?
Small hospitals and CAHs are not required to collect data on the PC chart-abstracted measures to meet their 2022 ORYX reporting requirements. However, those facilities providing obstetrical services may elect to use any of the PC measures (chart-abstracted and/or eCQMs) to meet their reporting requirement if they provide obstetrical services.
5.4: How many quarters of eCQMS need to be submitted by CAHs / Small Hospitals for CY 2022?
Any facility electing or required to submit eCQMs must submit a minimum of 3 quarters of eCQM data.
5.5: We are a Specialty Hospital; what are our ORYX reporting requirements?
The Specialty Hospital designation as it relates to ORYX Performance Measurement was removed effective CY2021. All hospitals previously designated as "Specialty" for ORYX reporting purposes are placed in the appropriate ORYX policy based upon number of Licensed Beds and/or Outpatient Visits. Please refer to the reporting requirements on our website or copy and paste the following web address into your internet browser: https://www.jointcommission.org/-/media/tjc/documents/measurement/oryx/2022-oryx-reporting-requirements--october-19-2021.pdf
5.6: Do inpatient psychiatric units or general medical/surgical hospitals that operate a separate psychiatric hospital surveyed and accredited under the main Joint Commission accredited hospital have to report on the HBIPS measures?
For Joint Commission purposes, accredited general medical/surgical hospitals with inpatient psychiatric units or operate a separate psychiatric hospital surveyed and accredited under the main Joint Commission accredited hospital are not required to report on the HBIPS measures, however, may do so if they choose. The CMS Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program includes inpatient psychiatric facilities and inpatient psychiatric units that bill under the Medicare Inpatient Psychiatric Facilities Prospective Payment System.
For Joint Commission reporting purposes, when determining the patient population to be included and sampled (using Global Sampling specifications), all applicable inpatients from across the accredited hospital must be included regardless of location, setting of care, and/or payment source.
Hospitals submitting HBIPS must implement the Joint Commission’s sampling requirements. CMS accepts the Joint Commission’s sampling requirements for their Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program
5.7: How is "Freestanding" Psychiatric Facility defined?
A facility that is 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 #.
5.8: Please clarify if the HBIPS-1 measure is required for Joint Commission Freestanding Psychiatric Hospitals, as this measure has never been required by CMS?
The Joint Commission ORYX reporting requirements are separate from the CMS Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program requirements. HBIPS-1 continues to be required for “freestanding” psychiatric hospitals along with HBIPS-2, HBIPS-3, and HBIPS-5.
5.9: Do psychiatric hospitals have to select and report on eCQMs?
For CY2022, there are no corresponding eCQMs available for selection by psychiatric facilities or inpatient psychiatric units. HBIPS, TOB, SUB, or IMM are only available as chart-abstracted measures and there are no corresponding eCQMs available for selection as additional measures for psychiatric facilities or inpatient psychiatric units.
5.10: Do Free-standing Children’s Hospitals, Long Term Acute Care Hospitals (LTACHs), Inpatient Rehabilitation Facilities (IRFs), HCOs Participating in CMS PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program have ORYX Reporting Requirements?
ORYX Performance Measurement Reporting Requirements for Free-standing Children’s Hospitals, Long Term Acute Care Hospitals (LTACHs), Inpatient Rehabilitation Facilities (IRFs), HCOs Participating in CMS PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program remain suspended.
5.11: Do you know if there is a plan to implement any performance measures for Children’s Hospitals, Long Term Acute Care Hospitals (LTACHs), Inpatient Rehabilitation Facilities (IRFs), or HCOs Participating in CMS PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program any time soon?
Not at this time. As hospitals select ORYX measures based on patient population/services offered, the Joint Commission does not have available ORYX chart-abstracted or eCQM measures to require data submission for these organizations with suspended ORYX requirements. At such time measures become available for consideration, the measures will be evaluated for use in the ORYX requirements for the Hospital Accreditation Program.