2024 Joint Commission ORYX Requirements

Following in the footsteps of the 2024 IQR requirements, The Joint Commission (TJC) has just released its 2024 ORYX^®quality reporting initiative requirements. TJC did make some notable changes to the 2024 requirements as compared to your 2023 requirements.

The CMS IQR and ORYX^® programs mostly align, but there are some differences to keep track of. Let’s jump in and review the major changes to the ORYX^® program and then go over the actual requirements for 2024.

ORYX® Program Notable Changes

PC Measures Required for Everyone with OB Services

Next year, TJC is getting rid of the concept of “number of live births”. You will participate either as a Large HAP (Hospital Accreditation Program) or and Small HAP or Critical Access Hospital (CAH). Large hospitals are defined as more than or equal to 26 licensed beds OR more than or equal to 50,000 outpatient visits. Small hospitals are defined as less than 26 beds AND less than 50,000 outpatient visits.

If you are a Large hospital that provides ANY obstetrical services, you must meet this year’s PC requirements regardless of birth volume.

Furthermore, TJC is removing the requirement to submit PC-01, PC-02, and PC-05 as abstracted measures. Instead, hospitals must submit PC-02 and PC-07 as eCQMs. This is in alignment with the CMS IQR requirements. However, they have retained the requirement for hospitals to submit PC-06 as a chart-abstracted measure, but you can submit it as an eCQM and still meet that requirement.

NHSN measures added to the program

Starting July 1, 2024, all hospitals who are reporting National Healthcare Safety Network (NHSN) measures through a CMS program are required to join The Joint Commission NHSN Group. This means NHSN will give TJC access to your performance on CAUTI, CLABSI, CDI, MRSA, SSI: Colon, and SSI: Hysterectomy. They don’t mention how they intend to use this data, but they will release more information on how this will work by the end of the year or early next year.

Enforcing TJC Requirements

TJC wants to enforce these ORYX^® requirements. They note that starting January 1, 2024, if your hospital or Critical Access Hospital fails to meet ORYX^® performance measure reporting requirements for two consecutive years, in the absence of an approved extenuating circumstance from TJC, you may receive a denial of accreditation.

Added and Retired measures

eCQMs

TJC is adding two new eCQMs (also available in IQR):

1. Hospital Harm—Opioid-Related Adverse Events (HH-ORAE)
2. Global Malnutrition Composite Score (GMCS)

They are retiring two eCQMs as well (both are also being retired in IQR) :

1. Admit Decision Time to ED Departure Time for Admitted Patients (ED-2)
2. Discharged on Statin Medication (STK-6) [Note: the chart-abstracted STK-6 measure remains required for applicable TJC stroke certification programs]

As of now, TJC still will not publicly report eCQM results (IQR eCQM results are publicly reported on Care Compare).

Abstracted Measures

SDOH Measures

There are two new chart-abstracted measures available. They are….wait for it…the SDOH measures from the CMS IQR program. Don’t panic. They aren’t required for ORYX^® submission.

I’ll admit, we were scratching our heads at this one. CMS specified these as process measures in the IQR program, which means you simply attest to the populations at the end of the year. TJC now has these as abstracted measures, which follow the forth quarter (4Q) annual abstracted measure submission deadline. And, by the way, Medisolv specified these as eCQMs, which would allow you to meet both submission requirements.

1. Screening for Social Drivers of Health (SDOH-1)
2. Screen Positive Rate for Social Drivers of Health (SDOH-2)

Additionally, TJC will retire these two chart-abstracted measures:

1. Hospital-Based Inpatient Psychiatric Services – Multiple Antipsychotic Medications at Discharge with Appropriate Justification (HBIPS-5)
2. Tobacco Treatment Measures – Tobacco Use Treatment Provided or Offered (TOB-2) and Tobacco Use Treatment (TOB-2a)

That covers the major changes you should be aware of. Now let’s move on to the requirements for the ORYX^® program in 2024.

2024 TJC ORYX® Program Requirements

For reference, here is The Joint Commission’s PDF of 2024 requirements.

eCQM ORYX® Requirements

In 2024, hospitals must submit the three required eCQMs and select three other eCQMs for a total of six eCQMs. Hospitals must submit all four quarters of data and the eCQMs must be the same for all four quarters.

Notes: 

Only hospitals with OB services are required to submit the PC eCQMs.

If you choose to submit PC-06 as an eCQM instead of as a chart-abstracted measure (which is allowed under this year’s chart-abstracted measure requirements), it counts as one of your three other eCQMs.

If you choose to submit the STEMI eCQM (OP-40 Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED)) as one of your three other eCQMs, you only have to submit one quarter of data in 2024 (like in the CMS OQR program).

Requirement:

Chart-Abstracted Measure ORYX® Requirements

As mentioned above, this year TJC is requiring all large hospitals with OB services to submit PC data, regardless of birth volumes, but you only are required to submit PC-06: Newborn Complications.

Note: 

For PC-06, hospitals may submit data as a chart-abstracted measure, or eCQM. If you choose to submit as an eCQM, it counts toward the minimum requirement for that category.

CMS has removed the HBIPS-5 measure from the program.

Requirement:

NHSN ORYX® Requirements

Starting July 1, 2024, all hospitals and Critical Access Hospitals must participate in the TJC NHSN group.

Note: 

Only hospitals participating in the NHSN measures through a CMS requirement will be required to join the TJC NHSN Group. This will give TJC access to your hospital’s performance on the NHSN measures listed below.

Requirement:

Facilities with Suspended Requirements

The following facilities are exempt from The Joint Commission ORYX^® requirements in 2024:

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