2025 Joint Commission ORYX Requirements

The Joint Commission has just released its 2025 ORYX^® program requirements, and for once you may be able to breathe a sigh of relief. That’s because, much like CMS’s 2025 IQR Program requirements, not a whole lot has changed this year. Furthermore, ORYX^® requirements continue to align strongly with CMS’s IQR requirements, so once you figure out one program, you’re more than halfway home on the other.

That being said, don’t assume you can rest on your laurels in 2025. Focus the year’s efforts on optimizing your performance around your hospital’s priority and/or underperforming measures. Pay particular attention to your eCQMs, since we can safely assume CMS (and therefore TJC) will begin ramping up eCQM requirements next year.

Now that you’ve heard our usual “use your time to get a head start” advice (trust us, it’s what separates good hospitals from great ones), let’s dive into your 2025 ORYX to-do list.

ORYX® Program Notable Changes

Mandatory eCQM Reporting for Small Hospitals and Critical Access Hospitals

For the first time ever, small hospitals and critical access hospitals are required to submit at least one eCQM. This self-selected eCQM must include 4 quarters of data. Up until now, eCQMs have been an optional measure type for this group. In general, all hospitals, regardless of size or service lines, should expect more eCQMs to be added to their mandatory list over the next several years as TJC continues to follow CMS’s lead towards all-digital quality measurement.

New eCQMs Available

TJC is adding three new optional eCQMs that you can use to meet your ORYX requirements. All three measures are also available in CMS’s 2025 IQR and OQR programs:

• HH-PI: Hospital Harm -Pressure Injury 
• IP-ExRad: Excessive Radiation Dose or Inadequate Image Quality for Computed Tomography (CT) in Adults (Inpatient)
• OP-ExRad: Excessive Radiation Dose or Inadequate Image Quality for Computed Tomography (CT) in Adults (Outpatient)

Updated Outpatient eCQM Requirements

If you plan to report either of the outpatient eCQMs (OP-40: ST-Segment Elevation Myocardial Infarction (STEMI) or OP-ExRad) this year, please note that TJC has aligned with CMS for the number of required quarters to submit. For STEMI, you must now submit two quarters to meet the measure’s requirements. For OP-ExRad, you must submit one quarter.

Retired Abstracted Measures

TJC is retiring just one chart-abstracted measure from your list of options: VTE-6: Hospital Acquired Potentially-Preventable Venous Thromboembolism.

REMINDER! TJC Requirements Enforcement

Last year was the first year that TJC started enforcing its requirements in earnest. As of January 1, 2024, any hospital or critical access hospital that fails to meet its ORYX^® performance measure reporting requirements for two consecutive years may receive a denial of accreditation (barring an approved extenuating circumstance from TJC). In other words, if you failed to meet your 2024 requirements, failure is not an option this year.

2025 TJC ORYX® Program Requirements

For reference, here is The Joint Commission’s complete rundown of its 2025 ORYX Performance Measurement Reporting Requirements.

eCQM ORYX® Requirements

For most hospitals, the eCQM requirements haven’t changed this year (the one exception being the new eCQM requirement for small/critical access hospitals we noted above). You are still being tasked with submitting three mandated eCQMs and three self-selected eCQMs for a total of six. With the exception of the two outpatient eCQMs noted below, you must submit all four quarters of data for each eCQM you submit.

TJC has still not announced any formal plans to publicly report eCQM results, saying the decision remains under evaluation. (IQR eCQM results are published by CMS).

Notes: 

• Only hospitals with OB services are required to submit the PC eCQMs. As a reminder, if you are a large hospital that provides ANY obstetrical services, you must meet this year’s PC requirements, regardless of your birth volume.
• If you choose to submit PC-06 as an eCQM instead of as a chart-abstracted measure (which is allowed once again under this year’s chart-abstracted measure requirements), it counts as one of your three other eCQMs. If submitting PC-06 as an eCQM, PC attestation is required when you’re submitting your data.
• If you choose to submit the outpatient STEMI eCQM (OP-40) as one of your three other eCQMs, you only have to submit two quarters of data. This aligns with the OQR program’s requirements.
• If you choose to submit the new outpatient ExRad eCQM (OP-ExRad), you only have to submit one quarter of data.

Requirement:

Chart-Abstracted Measure ORYX® Requirements

Just like CMS, continues to slowly back away from chart-abstracted measures. In fact, with the exception of freestanding psychiatric facilities, hospitals can choose to bypass chart-abstracted measures all together in favor of their eCQM counterparts.

Requirement:

NHSN ORYX® Requirements

All hospitals who are reporting National Healthcare Safety Network (NHSN) measures through a CMS program are required to participate The Joint Commission NHSN Group. The deadline to enroll was July 1,2024; be sure to check with your accreditation point person to ensure this has happened.

This requirement gives TJC access to your performance on CMS’s CAUTI, CLABSI, CDI, MRSA, SSI: Colon, and SSI: Hysterectomy measures. TJC believes this data will provide a more up-to-date and accurate look at hospital performance around preventing healthcare-associated infections (HAIs). Up until now, TJC has only had CMS’s Care Compare data—which is 18-24 months old—to examine HAI performance. Click here for TJC’s complete NHSN rationale and requirements.

Requirement:

Facilities with Suspended Requirements

The following facilities are exempt from The Joint Commission ORYX^® requirements in 2025:

• • 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

Master your 2025 Reporting Requirements with Medisolv

Did you know Medisolv’s Hospital Quality Reporting Package makes it easy to manage all of your reporting requirements—including the CMS IQR, OQR, and TJC Oryx programs—all in one place? Contact us to schedule a free demo now, or check out these free tools from our Education Center:

• eBook: 2025 IQR Reporting Requirements
• Webinar: 2025 IPPS Final Rule – What You Need to Know
• Report: eCQM Benchmark Report and Top-Performing Hospitals