to main content Accreditation - ORYX | 91㽶Ƶ

91㽶Ƶ

Facts about ORYX for Hospitals

  • 91㽶Ƶ’s ORYX initiative integrates performance measurement data into the accreditation process.
  • ORYX measurement requirements support Joint 91㽶Ƶ-accredited organizations in their quality improvement efforts.
  • 91㽶Ƶ continues to align measures as closely as possible with the Centers for Medicare & Medicaid Services (CMS).

The following sections provide the ORYX reporting requirements for the respective year and links to important resources and supporting material.


Please see Resources for additional information regarding submission timelines, key communications, and FAQs.

91㽶Ƶ updated the 2024 ORYX Performance Measure reporting requirements effective January 1, 2024. These requirements apply to Joint 91㽶Ƶ–accredited critical access hospitals and hospitals.

All HCOs with ORYX requirements should review the full document: 2024: ORYX Performance Measurement Reporting Requirements

Key 2024 updates include the following: 

  • 2 new eCQMs will be available to meet ORYX eCQM submission requirements:
    • Hospital-Harm—Opioid Related Adverse Events eCQM (HH-ORAE)
    • Global Malnutrition Composite Score eCQM (GMCS)
  • 91㽶Ƶ will retire 2 eCQMs effective January 1, 2024:
    • Admit Decision Time to ED Departure Time for Admitted Patients (eED-2) 
    • Discharged on Statin Medication (eSTK-6) [Note: the chart-abstracted STK-6 measure remains required for applicable Stroke certification programs]
  • 2 new chart-abstracted measures will be available to meet ORYX measure submission requirements:
    • Screening for Social Drivers of Health (SDOH-1)
    • Screen Positive Rate for Social Drivers of Health (SDOH-2)
  • 91㽶Ƶ will retire 2 chart-abstracted measures effective January 1, 2024:
    • Hospital-Based Inpatient Psychiatric Services - Multiple Antipsychotic Medications at Discharge with Appropriate Justification (HBIPS-5)  
    • Tobacco Treatment Measures - Tobacco Use Treatment Provided or Offered (TOB-2) and Tobacco Use Treatment (TOB-2a)
  • Applicable to [Large] Hospitals (HAP) with ≥26 Licensed beds OR ≥50,000 Outpatient visits AND Provide Obstetrical Services:
    • The PC requirements will no longer be based on annual live birth volume; PC requirements apply to large hospital facilities that provide obstetrical services.
  • Effective January 1, 2024, hospitals and critical access hospitals with ORYX performance measurement requirements may receive a Denial of Accreditation if they fail to meet ORYX performance measure reporting requirements for two consecutive years in the absence of receipt of an approved extenuating circumstance request from 91㽶Ƶ. For additional information, see the September 20, 2023 announcement in .
  • Acute care hospitals will be required to join the Joint 91㽶Ƶ National Healthcare Safety Network (NHSN) Group. Information on the process to join 91㽶Ƶ NSHN group will be distributed during late 2023 and early 2024.

Please see Resources for additional information regarding submission timelines, key communications, and FAQs.

2023: ORYX Performance Measurement Reporting Requirements

91㽶Ƶ updated the 2023 ORYX Performance Measure reporting requirements effective January 1, 2023. These updates affect reporting requirements for Joint 91㽶Ƶ–accredited critical access hospitals and hospitals. Key updates include: 

  • 3 New eCQMs will be available to meet ORYX eCQMs submission requirements: 
    • Hospital Harm—Severe Hypoglycemia Measure 
    • Hospital Harm—Severe Hyperglycemia Measure 
    • ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED) 
  • Hospitals that are required or elect to submit eCQMs are required to submit eCQM data on a minimum of four (4) eCQMs for all four quarters starting with 2023 discharges. 
  • 91㽶Ƶ will retire chart-abstracted HBIPS-1. 

Additionally, CMS and 91㽶Ƶ will both include maternal care eCQMs ePC-02 and ePC-07 as optional measures for the 2023 measure collection year. 91㽶Ƶ made these measures available as optional measures to satisfy 2022 ORYX Performance Measure requirements.  

Please see Resources for additional information regarding submission timelines, key communications, and FAQs.

2022: ORYX Performance Measurement Reporting Requirements

91㽶Ƶ updated the 2022 ORYX Performance Measure reporting requirements effective January 1, 2022. These updates affect reporting requirements for Joint 91㽶Ƶ–accredited critical access hospitals and hospitals. Key updates include:

  • In 2022, hospitals will begin using the new Joint 91㽶Ƶ Direct Data Submission Platform (DDSP) for submission of both electronic clinical quality measure (eCQM) and chart-abstracted data submission. The new Joint 91㽶Ƶ DDSP will become available for data submission in the second half of 2022. A more specific timeline will be communicated when the platform launch date has been determined.
  • Health Care Organizations (HCOs) that are required or elect to submit eCQMs are required to submit eCQM data for a minimum of three self-selected quarters, applicable to the services provided and patient populations served.
  • If an HCO is required but is unable to submit eCQM data, the HCO must submit an extenuating circumstance request (ECR) form prior to the chart-abstracted deadline.
  • HCOs must submit a new ECR form for each year and in no case may an HCO be granted an exception for more than five consecutive years.

2021: ORYX Performance Measure Reporting Requirements

For CY2021 discharges, Accredited hospitals submit both electronic clinical quality measure (eCQM) and chart-abstracted measure data via 91㽶Ƶ’s Direct Data Submission Platform (DDSP). eCQM data is submitted to 91㽶Ƶ on a yearly basis. Chart Abstracted measure data is submitted as monthly aggregate data on a quarterly basis.

  • Acute Care Hospitals having Licensed Beds >= 26 OR Outpatient Visits >= 50,000 and 300+ live births annually submit four chart-abstracted measures (PC-01, PC-02, PC-05 and PC-06), and select a minimum of 4 eCQMs, reporting the same eCQMs for two self-selected quarters. There are twelve eCQMs available.
  • Acute Care Hospitals having Licensed Beds >= 26 OR Outpatient Visits >= 50,000 and 1-299 live births annually submit one chart-abstracted measures (PC-01), and select a minimum of 4 eCQMs, reporting the same eCQMs for two self-selected quarters. There are twelve eCQMs available.
  • Acute Care Hospitals having Licensed Beds >= 26 OR Outpatient Visits >= 50,000 and do not provide obstetrical service do not submit chart-abstracted measures, and select a minimum of 4 eCQMs, reporting the same eCQMs for two self-selected quarters. There are twelve eCQMs available.
  • Hospitals having Licensed Beds <26 AND Outpatient Visits < 50,000 (small hospitals), are required to submit any combination of three (3) eCQMs and/or chart-abstracted measures applicable to patient population/services offered.
  • Critical Access Hospitals (CAHs) are required to submit any combination of three (3) eCQMs and/or chart-abstracted measures applicable to patient population/services offered.
  • Freestanding Psychiatric Hospitals continue to report on the four required Hospital-Based Inpatient Psychiatric Services (HBIPS) measures (HBIPS-1, HBIPS-2, HBIPS-3, and HBIPS-5).
  • Free-standing Children’s Hospitals, Long Term Acute Care Hospitals (LTACHs), Inpatient Rehabilitation Facilities (IRFs) and HCOs participating in CMS PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) program reporting requirements remain suspended.
  • 91㽶Ƶ has eliminated “self-reporting” of ORYX data. Hospitals that self-reported performance measurement data in the past are now expected to submit their data, starting CY2021, to the Direct Data Submission Platform (DDSP).

2020: ORYX Performance Measure Reporting Requirements

For CY2020 discharges, Accredited hospitals now submit both electronic clinical quality measure (eCQM) and chart-abstracted measure data via 91㽶Ƶ’s Direct Data Submission Platform (DDSP).

  • eCQM data is submitted to 91㽶Ƶ on a yearly basis.
  • Chart Abstracted measure data is submitted as monthly aggregate data on a quarterly basis.

Hospital Accreditation program with average daily census (ADC) >10

  • Report a minimum of four (of 10 available) eCQMs for one self-selected calendar quarter via DDSP.
  • Hospitals providing obstetrical services report via DDSP on one required chart-abstracted measure — perinatal care (PC) measure PC-01.
  • Hospitals with at least 300 live births per year — in addition to PC-01 — report via DDSP on all chart-abstracted PC measures (PC-02, PC-05, and PC-06). 
    Note: Effective 1/1/2020 PC-03 and PC-04 have been retired for accreditation and certification purposes.

Critical access hospitals, small hospitals with ACD <10 inpatients, and ORYX®-designated specialty program

  • Report on a choice of three available measures (chart-abstracted or eCQMs
  • These hospitals remain exempt from requirement to submit data to 91㽶Ƶ. If data are not submitted, the organization is required to make data reports available for review by surveyors during on-site surveys.

Freestanding Psychiatric Hospitals Accreditation program

  • Report via DDSP on the four required hospital-based inpatient psychiatric services (HBIPS) measures (HBIPS-1, HBIPS-2, HBIPS-3, and HBIPS-5).

Hospital Accreditation programs for which ORYX performance measure reporting requirements continue to be suspended

  • Suspension of requirements continues for freestanding children’s hospitals, long-term acute care hospitals and inpatient rehabilitation facilities.