Joint Commission Online - Nov. 1, 2023
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
November 01, 2023
The Joint Commission finalized the 2024 ORYX performance measure reporting requirements, effective Jan. 1, 2024, for critical access hospitals and hospitals. A notable change for the coming year is that acute care hospitals and critical access hospitals must join the Joint Commission National Healthcare Safety Network (NHSN) Group. The Joint Commission identified the U.S. Centers for Disease Control and Prevention (CDC) NHSN system as a data source to identify patient safety and quality performance by Joint Commission-accredited hospitals that already participate in NHSN as required by the U.S. Centers for Medicare & Medicaid Services (CMS) programs.
There are several measures collected through NHSN applications that are currently included in the Accelerate PI™ dashboards. However, these data come from the publicly available CMS Compare website where the data can be 18-24 months old. Sharing NHSN data will allow The Joint Commission to include more recent data in Accelerate PI dashboards and identify quality improvement opportunities.
Acute care hospitals and critical access hospitals are required to join the Joint Commission Group within the NHSN application by accepting the template of rights to share data without any identifiers. No patient identifiers will be shared with The Joint Commission. Hospital data remain confidential and will not be shared with other Joint Commission-accredited hospitals. In accordance with NSHN Group rules “A facility that joins a Group does not have access to any data from other facilities in the Group.”
Beginning July 1, 2024, hospitals must allow The Joint Commission to access de-identified data on the following five CDC NHSN hospital-associated infection (HAI) measures from the NHSN application. All these measures are currently in the CMS Hospital Value-Based Purchasing (VBP) Program and the Hospital-Acquired Condition (HAC) Reduction Program.
- Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure
- Facility-Wide Inpatient Hospital-Onset Clostridium difficile Infection (CDI) Outcome Measure
- Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure
- Colon and Abdominal Hysterectomy Surgical Site Infection (SSI) Outcome Measure
- Facility-Wide Inpatient Hospital-Onset Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure
Information about joining the Joint Commission NSHN group will be distributed to organizations in late 2023 and early 2024.
November 01, 2023
The Joint Commission’s 2024 ORYX® performance measure reporting requirements – effective Jan. 1, 2024 – for critical access hospitals and hospitals, include the following:
- Acute care hospitals and critical access hospitals must join the Joint Commission National Healthcare Safety Network (NHSN) Group. (See the article, "2024 ORYX® Performance Measure Reporting Requirements include joining NHSN" for more information.)
- New decision rule to reinforce that critical access hospitals and hospitals participate in the ORYX performance measurement initiative. Organizations may receive a Denial of Accreditation if they do not meet ORYX performance measure reporting requirements for two consecutive years, unless they have an extenuating circumstance request approved by The Joint Commission.
- Two new electronic clinical quality measures (eCQMs) to meet ORYX eCQM submission requirements:
- Hospital-Harm—Opioid-Related Adverse Events eCQM (HH-ORAE)
- Global Malnutrition Composite Score eCQM (GMCS)
- Two new additional measures to meet ORYX measure submission requirements:
- Screening for Social Drivers of Health (SDOH-1)
- Screen Positive Rate for Social Drivers of Health (SDOH-2)
- Four measures retired as of 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.
- For large hospitals with ≥ 26 licensed beds or ≥ 50,000 outpatient visits and that provide obstetrical services, the following changes apply:
- The Perinatal Care (PC) requirements are no longer based on annual live birth volume; PC requirements apply to large hospital facilities that provide obstetrical services.
- The Joint Commission will align with the U.S. Centers for Medicare & Medicaid Services (CMS) and require eCQM submission of Cesarean Birth (ePC-02), Severe Obstetric Complications (ePC-07), and Safe Use of Opioids (eOPI-1), plus three additional self-selected eCQMs that apply to patient population/services from the list of available eCQMs.
- The Joint Commission requires submission of Unexpected Complications in Term Newborns (PC-06), either a chart-abstracted measure or an eCQM; if submitted as an eCQM, it counts toward the eCQM minimum requirement.
- PC-01 and PC-05 are no longer required for accreditation but will remain available as both chart-abstracted and eCQM measures. Note: Both PC-01 and PC-05 remain required for advanced certification in perinatal care.
- For large hospitals with ≥ 26 licensed beds or ≥ 50,000 outpatient visits and that do not provide obstetrical services, the following changes apply:
- The Joint Commission will align with CMS and require eCQM submission of Safe Use of Opioids, plus three additional self-selected eCQMs applicable to patient population/services from the list of available eCQMs.
- No chart-abstracted measure requirements for these organizations, but they may choose to submit chart-abstracted measures.
- For small hospitals with < 26 licensed beds and < 50,000 outpatient visits and critical access hospitals, the following changes apply:
- Organizations must submit any combination of three measures applicable to patient population/services offered.
- Critical access hospitals may submit chart-abstracted measures for all four quarters and/or eCQMs for all four quarters.
- The PC requirement does not apply to these facilities; however, if they provide obstetrical services and choose to report, they may submit PC measures to meet ORYX requirements.
- For separately accredited freestanding psychiatric hospitals, measure requirements include HBIPS-2, HBIPS-3, and one additional self-selected measure applicable to patient population/services from the list of available measures.
For more information, view the On Demand Webinar on the Joint Commission’s 2024 ORYX performance measure reporting requirements. Specifications for the eCQMs are available on the Electronic Clinical Quality Improvement (eCQI) Resource Center website. For more information and a detailed list of all requirements and measures for critical access hospitals and hospitals, visit the Joint Commission’s ORYX Performance Measurement Reporting page.
November 01, 2023
The Joint Commission posted an updated 2024 ORYX performance measure reporting requirements document, effective Jan. 1, 2024, for assisted living communities. The key update, announced in the April 2023 issue of Perspectives, is that reporting is required beginning calendar year 2024. Assisted living communities must report on all measures for all four quarters.
For more information and a detailed list of all requirements and measures for assisted living communities, visit the Joint Commission’s ORYX Performance Measurement Reporting page. Questions regarding these updates and requirements may be directed to the ORYX Help Line.