The Joint Commission’s 2025 ORYX® performance measure reporting requirements that are effective Jan. 1, 2025, for all Joint Commission accredited critical access hospitals and hospitals are described below.
Updates for 2025 include the following:
For small hospitals with < 26 licensed beds and < 50,000 outpatient visits and critical access hospitals:
- Submit no fewer than one electronic clinical quality measure (eCQM) for the entire calendar year.
- Submit two additional measures applicable to the patient population/services offered (they may be chart-abstracted measures [CAMs], eCQMs, or a
- combination of both).
- Reporting on the Safe Use of Opioids – Concurrent Prescribing eCQM is highly encouraged.
Added the following optional eCQMs to meet reporting requirements:
- Hospital Harm – Pressure Injury (HH-PI)
- Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Inpatient) (IP-ExRad)
- 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:
- ST-Segment Elevation Myocardial Infarction (STEMI) (OP-40)—submit a minimum of two self-selected quarters
- 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 CY2024 requirements remain unchanged in CY2025:
Large hospitals with ≥ 26 licensed beds or ≥ 50,000 outpatient visits and that do provide obstetric services must continue reporting on the following:
- Cesarean Birth (PC-02 eCQM)
- Severe Obstetric Complications (PC-07 eCQM)
- 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.)
- Safe Use of Opioids – Concurrent Prescribing (eCQM)
- Three additional self-selected eCQMs applicable to the patient population/services offered
Psychiatric hospitals must continue reporting on the following:
- Hospital-Based Inpatient Psychiatric Services – Hours of Physical Restraint Use (HBIPS-2)
- Hospital-Based Inpatient Psychiatric Services – Hours of Seclusion Use (HBIPS-3)
- One additional self-selected measure applicable to the patient population/services offered
Note that The Joint Commission made no changes to the CY 2025 ORYX performance measures or measure requirements for assisted living communities. For comprehensive details about all assisted living communities–related requirements and measures, visit The Joint Commission’s ORYX Performance Measurement Reporting for Assisted Living Communities page.
Questions regarding these updates and requirements may be directed to the ORYX Help Line.
Resources
ORYX Performance Measurement Reporting page: Detailed information and a complete list of all requirements and measures for critical access hospitals and hospitals.
Electronic Clinical Quality Improvement (eCQI) Resource Center website: Specifications for eCQMs.
Webinar replay on 2025 ORYX requirements for hospitals: This recorded Pioneers in Quality webinar was presented on Oct. 24, 2024. During the 90-minute webinar Joint Commission staff addressed the following topics:
- 2025 ORYX requirements for chart-abstracted measures and eCQMs for accredited hospitals and critical access hospitals
- ORYX policy requirements and rationale for changes that are effective for 2025
- Joint Commission measurement resources on the website, including measures list, high-level submission deadlines, measure specifications, FAQs, and quality measurement webinars and videos
Join The Joint Commission, Centers for Medicare & Medicaid Services, and Mathematica for the Expert to Expert webinar series, which addresses the eCQM Annual Updates for 2025 implementation. Common questions from JIRA and other sources will be addressed.
CEs will be offered for the webinars in this series that address 2025 Reporting Year eCQMs:
- STK-2, -3, -5
- VTE-1 and -2
- PC-02, -07
- Opioid Related Adverse Events
- Global Malnutrition Composite Score
- Hospital Harm: Pressure Injury
- Hospital Harm: Hyper/Hypo Glycemia
- Safe Use of Opioids – Concurrent Prescribing
- Hospital Harm: Acute Kidney Injury
- Hospital Harm: Excessive Radiation (both inpatient & outpatient settings)
For additional information on these webinars, visit the Expert to Expert webinars page (https://www.jointcommission.org/measurement/quality-measurement-webinars-and-videos/expert-to-expert-webinars/). Two December webinars are open for registration:
Dec. 5, 2024: STK-2, -3, and -5 webinar, register via this link: https://attendee.gotowebinar.com/register/7678576234798604125
Dec. 19, 2024: VTE-1, and -2 webinar, register via this link: https://attendee.gotowebinar.com/register/2011017105723720028
Determining the correct medical, ethical, and legal – and best – decision for a patient who is in a terminal state and unable to communicate their wishes is one of the most difficult clinical and moral challenges for the patient, the surgeon, and the patient’s family.
Making these difficult end of life decisions is the focus of a column in the October issue of the American College of Surgeons’ Bulletin, written by Lenworth M. Jacobs Jr., MD, MPH, FACS. The article covers The Joint Commission’s recently revised Rights and Responsibilities of the Individual requirements for accredited ambulatory surgical centers that further clarify who may exercise a patient’s rights on their behalf when the patient is unable to make decisions.
Modern medicine is now able to resuscitate and stabilize patients who in a previous era would not have survived the catastrophic event that caused them to require immediate hospital care. Examples of these kinds of events are major trauma with a prehospital cardiopulmonary arrest, a major cerebral hemorrhage, a prolonged cardiac arrest with cerebral anoxia, or a post-surgical event resulting in cerebral anoxia. All these scenarios can result in a patient who is being maintained on a ventilator with vasopressor support but who has no meaningful pathway to recovery.