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ORYX® for Hospitals Fact Sheet

(National Hospital Quality Measures)

 

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 U.S. Centers for Medicare and Medicaid Services.

The Joint Commission updated the 2025 ORYX® Performance Measure reporting requirements effective Jan. 1, 2025. These updates affect reporting requirements for Joint Commission-accredited critical access hospitals and hospitals. 

Key updates for calendar year (CY) 2025 include: 

  • For small hospitals with < 26 licensed beds and < 50,000 outpatient visits and critical access hospitals, the following changes apply: Must submit no fewer than one electronic clinical quality measure (eCQM) for the entire calendar year. 
    o Submit two additional measures applicable to the patient population/services offered (they may be chart-abstracted measures [CAMs], eCQMs, or a combination of both). 
    o Reporting on the Safe Use of Opioids – Concurrent Prescribing eCQM is highly encouraged. 
  • Added the following optional eCQMs to meet reporting requirements:
    o Hospital Harm – Pressure Injury (HH-PI) 
    o Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Inpatient) (IP-ExRad) 
    o Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Outpatient) (OP-ExRad) 
  • Included the following optional outpatient eCQMs to meet ORYX requirements that align with the U.S. 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. 
    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. 
  • VTE-6: Hospital Acquired Potentially-Preventable Venous Thromboembolism CAM will be retired Jan. 1, 2025. 

The following CY 2024 requirements remain unchanged in CY 2025: 

  • Large hospitals with ≥ 26 licensed beds or ≥ 50,000 outpatient visits and that do provide obstetric services must continue reporting on the following: 
    o Cesarean Birth (PC-02 eCQM) 
    o Severe Obstetric Complications (PC-07 eCQM) 
    o Unexpected Complications in Term Newborns (PC-06) Note that PC-06 submissions can be either CAM or eCQM. If submitting as an eCQM, the submission may be considered one of the three additional self-selected eCQMs. 
    o Safe Use of Opioids – Concurrent Prescribing (eCQM) 
    o Three additional self-selected eCQMs applicable to the patient population/services offered 

  • Large hospitals with ≥ 26 licensed beds or ≥ 50,000 outpatient visits and that do not provide obstetric services must continue reporting on the following:
    o Safe Use of Opioids – Concurrent Prescribing (eCQM) 
    o Three additional self-selected eCQMs applicable to the patient population/services offered. 

  • Psychiatric hospitals must continue reporting on the following: 
    o Hospital-Based Inpatient Psychiatric Services – Hours of Physical Restraint Use (HBIPS-2)
    o Hospital-Based Inpatient Psychiatric Services – Hours of Seclusion Use (HBIPS-3)
    o One additional self-selected measure applicable to the patient population/services offered.

A detailed list of all requirements and measures by organization type for 2025 are available via The Joint Commission’s ORYX Performance Measurement Reporting page.

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