2024 ORYX® Performance Measure Reporting Requirements include joining NHSN

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.

1. Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure
2. Facility-Wide Inpatient Hospital-Onset Clostridium difficile Infection (CDI) Outcome Measure
3. Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure
4. Colon and Abdominal Hysterectomy Surgical Site Infection (SSI) Outcome Measure
5. 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.