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2019 Joint Commission ORYX® Requirements

Every year, The Joint Commission requires its accredited hospitals to submit certain data as a part of their accreditation process. The ORYX® initiative for quality improvement is the name of the program to which your hospital must submit their data.

The Joint Commission does their best to align their requirements with the CMS Inpatient Quality Reporting (IQR) program, but there are slight differences. Just enough to confuse us all. 😑

The requirements listed below have since been updated in response to COVID-19. To read more about these changes, read our blog on quality reporting changes due to COVID-19.

Below we’ve outlined the 2019 requirements for the ORYX® program. We’ve also included a bundle package at the bottom which outlines the different requirements between the ORYX® and IQR programs.

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.

In response to COVID-19, The Joint Commission has made the following changes:

  • Q4 chart-abstracted data submission is optional.
  • If you do submit, TJC has extended the deadline for submission from April 30, 2020 to June 1, 2020.

Chart-abstracted measures

ED-2
PC-01

 

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
CAC-3 STK-5
ED-1 STK-6
ED-2 VTE-1
PC-01 VTE-2
PC-05 EHDI-1a
STK-2  

 

In addition, hospitals must choose to report on one self-selected quarter from 2019. The deadline to submit your measures is March 16, 2020.

 

eCQM Submission Method

This year, hospitals must use the new Direct Data Submission (DDS) Platform for eCQM submissions to The Joint Commission. This doesn't 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 platform is open now so you can start playing around in there and see how your data does or does not match up against your records. That’s what we are doing now for our clients so we suggest you do too … or you can call us. 😀


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-02
PC-03
PC-04
PC-05
*PC-06

*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

eCQMs

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 VTE-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.

In response to COVID-19, The Joint Commission has made the following changes:

  • Q4 data submission is optional.
  • If you do submit, TJC has extended the deadline for submission from April 30, 2020 to June 1, 2020.

 

HBIPS Chart-abstracted measures

HBIPS-1
HBIPS-2
HBIPS-3
HBIPS-5

 

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.

 

Get Ahead and Improve Your Quality

Medisolv Can Help

We've seen some big changes in The Joint Commission’s ORYX® program. With Medisolv as your partner we help guide you through every new change along the way. Talk with us about how we can help you track and improve your quality performance on measures like ePC-02!

Here are some additional resources you may find useful.

Blog Post: "2020 Joint Commission ORYX Requirements
Blog Post" "The Joint Commission Releases New eCQM in 2020: PC-02"
Blog Post: "How to Implement ePC-02

 

 

Erin Heilman

Erin Heilman is the Marketing Director for Medisolv, Inc.

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