2019 Joint Commission ORYX® Requirements

By Erin Heilman. Posted Oct 12, 2018 in Quality Reporting, Academy, IQR Program

Just when it feels like you’re nearing the end of your regulatory reporting duties for 2018...the time comes to start thinking ahead to a brand-new year of quality reporting. I know, the struggle is real. But by getting your research and planning done in advance, you’ll feel more confident about achieving quality reporting success in 2019.

In a previous post, we discussed the changes that have been finalized for the 2019 CMS Inpatient Quality Program (IQR) program. Today, we’re switching gears and reviewing what’s in store for another major regulatory program—The Joint Commission ORYX® initiative for quality improvement program.

So, what’s staying the same and what’s changing next year? Let’s review the 2019 requirements.

Chart-Abstracted Measure Requirements 

The Joint Commission made some chart-abstracted measure adjustments for 2019. Unlike 2018, hospitals are required to report on two chart-abstracted measures next year. These measures will need to be submitted on a quarterly basis for the entire 2019 calendar year.

Chart-abstracted measures



The following three chart-abstracted measures are no longer required, but will still remain in the program: ED-1, VTE-6 and IMM-2.

Chart-abstracted Submission Method

For chart-abstracted measure submissions, hospitals must use an approved vendor. You can review The Joint Commission’s approved vendor list here (find us on page three!).

eCQM Requirements

The eCQM reporting requirements will remain the same. In 2019, hospitals must continue to submit four of the available 13 eCQMs. 

Select and Report Four eCQMs

AMI-8a STK-3
ED-1 STK-6
ED-2 VTE-1
PC-01 VTE-2
PC-05 EHDI-1a


In addition, hospitals must choose to report on one self-selected quarter from 2019. The deadline to submit your measures is March 15, 2020.

eCQM Submission Method

eCQM submission requirements, however, have changed a bit. Starting in 2019, hospitals are being transitioned to The Joint Commission Direct Data Submission (DDS) Platform for eCQM submissions.

Breathe easy, this does not mean that you can’t use a vendor. Vendors can still submit your measures like in previous years, so don't stress about having to complete submissions on you own.

The Joint Commission will provide more information about the use of the DDS platform in 2019 soon. 

Special Facility Requirements

Hospitals with at least 300 live births

Hospitals with at least 300 births per year are required to submit five perinatal care measures in addition to the two chart-abstracted measures—ED-2 and PC-01—above.

Additional perinatal care measures


*PC-06, Unexpected Complications in Term Newborns, is a new measure that was added for 2019.

Critical Access and Small Hospitals

Critical access and small hospitals with an average daily consensus of 10 or fewer inpatients are required to report on three measures from any of the chart-abstracted or eCQM options below. This is down from the requirement of six measures in 2018.

Chart-abstracted measures


ED-1, ED-2 AMI-8a
PC-01, PC-02, PC-03, PC-04, PC-05, PC-06 CAC-3
VTE-6 ED-1, ED-2
IMM-2 PC-01, PC-05
HBIPS-1, HBIPS-2, HBIPS-3, HBIPS-5 eSTK-2, eSTK-3, eSTK-5, eSTK-6
TOB-2, TOB-3 VTW-1, VTE-2
SUB-2, SUB-3 EHDI-1a
OP-18, OP-23  


Freestanding Psychiatric Hospitals

In 2019, freestanding psychiatric hospitals must continue to report on the four Hospital-based Inpatient Psychiatric Services (HBIPS) chart-abstracted measures below. Just as with your chart-abstracted measures, these measures will need to be submitted on a quarterly basis for the entire 2019 calendar year.

HBIPS Chart-abstracted measures



Facilities with Suspended requirements

As in the past, the following facilities are exempt from The Joint Commission ORYX® requirements in 2019:

  • Freestanding Children’s Hospitals
  • Long Term Acute Care Hospitals
  • Inpatient Rehabilitation Facilities

Remember, Medisolv helps hospitals monitor and submit both chart-abstracted measures and eCQMs, year after year.

Why do it alone? Send us a note to learn more about our software, resources and clinical expert support. We’d love to chat and see how we can help with all of your quality reporting needs.


2019 Quality Reporting Bundle

Preparing to report your eCQM and chart-abstracted measure data to CMS and The Joint Commission can be overwhelming, especially if you're not sure what's required of you or where to search for accurate and up-to-date information. 

Set your uncertainties and worries aside. To help simplify the reporting process for your organization this year, we've put together a 2019 Quality Reporting Bundle which has all the important documents you'll need for a successful submission. 

 This bundle includes:

CMS IQR Program

  1. Reporting Requirements
  2. Measure List
  3. Deadlines

The Joint Commission ORYX® program

  1. Reporting Requirements
  2. Measure List
  3. Deadlines

An Acronym Reference Guide

, ,
Erin Heilman

Erin Heilman

Erin Heilman is the Marketing Director for Medisolv, Inc.

Quality Education Straight To Your Inbox

Sign up for our Academy to receive one educational email per week.

Resource Downloads