TJC & CMS News Blog
Information for

In a significant development, The Joint Commission has implemented updates to the 2024 ORYX Performance Measures reporting requirements, effective as of January 1, 2024. These changes are applicable to critical access hospitals, acute care hospitals, and freestanding psychiatric hospitals accredited by The Joint Commission.

What You Need to Know about 2024 ORYX Performance Measures

For all healthcare organizations (HCOs) with ORYX requirements, it is imperative to thoroughly review the comprehensive document titled “2024: ORYX Performance Measurement Reporting Requirements” to ensure compliance with the latest guidelines.

Freestanding Psychiatric Hospital 2024 ORYX Data Submission Requirements

  • HBIPS-2: Hours of Physical Restraint Use
  • HBIPS-3: Hours of Seclusion Use
  • One additional self-selected measure

It’s important to highlight that eCQMs are not applicable to Freestanding Psychiatric Hospitals. Additionally, it’s worth noting that participation in the Joint Commission NHSN Group is not a requirement for Freestanding Psychiatric Hospitals. Moreover, for these psychiatric hospitals, several additional chart-abstracted measures are available, including:

  • MM-2 (Influenza Immunization)
  • TOB-3 (Tobacco Use Treatment at Discharge)
  • SDOH-1 (Screening for Social Drivers of Health)
  • SDOH-2 (Screen Positive Rates for Social Drivers of Health)
  • SUB-2 (Alcohol Use Brief Intervention)
  • SUB-3 (Alcohol & Drug use Treatment at Discharge)

Keep in mind that when selecting chart-abstracted measures, it’s essential to ensure their relevance to the patient population and services provided by the organization. Additionally, organizations that choose to submit optional chart-abstracted measure(s) in Q1 2024 must commit to reporting these measures for the entire calendar year.

Be Aware

Starting from January 1, 2024, The Joint Commission is introducing a new decision rule for acute care hospitals, critical access hospitals, and psychiatric hospitals emphasizing the necessity of participation in the 2024 ORYX performance measures initiative. Organizations that do not meet the ORYX performance measure reporting requirements for two consecutive years, without having an approved extenuating
circumstance request (ECR) from The Joint Commission, may face the possibility of receiving a Denial of Accreditation.

Barrins & Associates Consultation

At Barrins & Associates we can assist you to achieve ongoing compliance with the 2024 ORYX performance measures for freestanding psychiatric hospitals. Inquire today about our consulting services. We continue to support your journey toward accreditation and regulatory compliance.

We continue to be your partner in achieving and sustaining Joint Commission Accreditation and regulatory compliance.