2025 ORYX® performance measure reporting requirements

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 .

 

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