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 Centers for Medicare & Medicaid Services.

The Joint Commission updated the 2024 ORYX® Performance Measure reporting requirements effective Jan. 1, 2024. These updates affect reporting requirements for Joint Commission-accredited critical access hospitals and hospitals, and include the following: 

• Effective Jan. 1, 2024, The Joint Commission is implementing a new decision rule applicable to hospitals and critical access hospitals with ORYX performance measurement requirements, to reinforce the requirement to participate in the ORYX performance measurement initiative. Organizations may receive a Denial of Accreditation if they fail to meet ORYX performance measure reporting requirements for two consecutive years in the absence of receipt of an approved extenuating circumstance request from The Joint Commission. See Key Communications for additional information.

• Acute care hospitals and critical access hospitals will be required to join the Joint Commission National Healthcare Safety Network (NHSN) group. Information on the process to join The Joint Commission NSHN group will be distributed during late 2023 and early 2024. See the November Perspectives® article for additional information.

• Two new electronic clinical quality measures (eCQMs) will be available to meet ORYX eCQM submission requirements.
  • Global Malnutrition Composite Score eCQM (GMCS)
  • Hospital-Harm — Opioid Related Adverse Events eCQM (HH-ORAE)

• Two new chart-abstracted measures will be available to meet ORYX measure submission requirements:
  • Screening for Social Drivers of Health (SDOH-1)
  • Screen Positive Rate for Social Drivers of Health (SDOH-2)

• The Joint Commission will retire four measures beginning Jan. 1, 2024:
  • Chart-abstracted Hospital-Based Inpatient Psychiatric Services – Multiple Antipsychotic Medications at Discharge with Appropriate Justification (HBIPS-5)
  • Chart-abstracted Tobacco Treatment Measures – Tobacco Use Treatment Provided or Offered (TOB-2) and Tobacco Use Treatment (TOB-2a)
  • eCQM Emergency Department (ED) – Admit Decision Time to ED Departure Time for Admitted Patients (eED-2)
  • eCQM Stroke – Discharged on Statin Medication (eSTK-6) [Note: the chart-abstracted STK-6 measure remains required for applicable Stroke certification programs]

• Perinatal Care (PC) requirements will no longer be based on annual live birth volume; PC requirements are applicable to large hospitals with ≥26 licensed beds OR ≥50,000 outpatient visits AND provide obstetrical services.

Read more

• Performance measurement webpage
• Questions on ORYX: