2023 Joint Commission ORYX Requirements

The Joint Commission had a bit of a rough year. After announcing, rather abruptly, that their DDS platform was shut down, they went about rebuilding it and severely delayed submission deadlines to the ORYX^® program. Submissions for 2021 reporting is opening this fall and then 2022 reporting is opening in January of 2023. 

In September, The Joint Commission (TJC) released their 2023 requirements for the ORYX^® quality improvement initiative. They made some minor adjustments to the abstracted and eCQM requirements, but they did not fully adopt the CMS measure list or requirements. This will make it challenging for your team to keep up with what's required in each program. Thankfully the major requirements look similar. You'll just have to do a bit more in the IQR program than with ORYX^®.

Let’s review some of the major changes to the ORYX^® program and then go over the actual requirements for 2023.

ORYX® Program Notable Changes

1. You must submit all four quarters of eCQM data instead of three (same as IQR).
2. There are three new eCQMs available (also available in IQR/OQR):
   1. Hospital Harm—Severe Hypoglycemia Measure
   2. Hospital Harm—Severe Hyperglycemia Measure
   3. ST-Segment Elevation Myocardial Infarction (STEMI)
3. TJC is retiring HBIPS-1 as a chart-abstracted measure.
4. TJC is not adopting these measures but CMS is (SEP-1, Hospital Commitment to Health Equity, Screening for Social Drivers of Health, Screen Positive Rate for Social Drivers of Health).
5. As of now, TJC still will not publicly report eCQM results (IQR eCQM results are published by CMS).
6. If your hospital is required to submit eCQMs, but unable to, then you must submit an extenuating circumstance request (ECR) form prior to the chart-abstracted deadline and must submit 3 chart-abstracted measures for all four quarters of 2023 instead. Hospitals must submit a new ECR form each year.

That covers the major changes you should be aware of. Now let’s move onto the requirements for the ORYX^® program in 2023.

2023 TJC ORYX® program requirements

For reference, here is The Joint Commission’s PDF of 2023 requirements.

Chart-abstracted measure ORYX® requirements

The Joint Commission abstracted measure requirements essentially remain the same. Remember that Critical Access Hospitals are now required to submit data (abstracted and/or eCQMs).

Note: For any or all of the required chart-abstracted Perinatal Care Measures (PC-01, PC-02, PC-05 and PC-06), hospitals may submit a minimum of four quarters of the associated PC eCQM instead of four quarters of the corresponding chart-abstracted measure. Also note, PC-07 is available as an eCQM but not an abstracted measure. 

Requirement:

eCQM ORYX® requirements

In 2023, hospitals must submit all four quarters of data instead of three quarters. The eCQMs must be the same for all four quarters. Remember that this data must still be submitted via the DDS platform, but unlike the abstracted measures, eCQMs must still contain patient-level data in the form of a QRDA I file format. Also, as of now, TJC will still not publicly report eCQM results unlike CMS who publishes the IQR eCQM results.

Note: For any or all of the required chart-abstracted Perinatal Care Measures (PC-01, PC-02, PC-05 and PC-06), hospitals may submit a minimum of four quarters of the associated PC eCQM instead of four quarters of the corresponding chart-abstracted measure. Also note, PC-07 is available as an eCQM but not an abstracted measure. 

Requirement:

Facilities with suspended requirements

As in the past, the following facilities are exempt from The Joint Commission ORYX^® requirements in 2023:

• Freestanding Children’s Hospitals
• Long Term Acute Care Hospitals
• Inpatient Rehabilitation Facilities
• Hospitals participating in the CMS PPS-Exempt-Cancer Hospital Quality Reporting program