September 2, 2015

Dear Colleague:

The Joint Commission is pleased to announce that it will continue to provide its accredited hospitals and Critical Access Hospitals with flexibility in meeting ORYX performance measure reporting requirements for calendar year 2016. The Centers for Medicare & Medicaid Services (CMS) has made multiple changes in its Hospital Inpatient Quality Reporting Program., and we have made changes to continue toalign as closely as possible with those of CMS.

ORYX Measure changes for 2016

Chart-abstracted measures

  • Retire
  • AMI-7a
  • CAC-3
  • SCIP-Inf-4
  • IMM-1
  • STK-1, STK-2, STK-3, STK-5, STK-6, STK-8, STK-10
  • VTE-1, VTE-2, VTE-3
  • HBIPS-4, HBIPS-6, HBIPS-7

electronic Clinical Quality Measures (eCQMs)

  • Add
  • AMI-8a
  • EHDI-1a (Early Hearing Detection and Intervention)

Chart-abstracted Sepsis Bundle Project (SEP-1) measure

  • Collected for CMS Only, Early Management Bundle, Severe Sepsis/Septic Shock

See Joint Commission Measure Sets Effective January 1, 2016: posted under the “Measurement” section of The Joint Commission’s website, ORYX Performance Measurement Reporting at

2016 Flexible ORYX Performance Measure Reporting Options and Requirements Effective January 1, 2016

  • Continue reporting on a minimum of six sets of measures (four sets for Critical Access Hospitals) based on services provided and populations served.
  • The threshold for mandatory reporting of the Perinatal Care (PC) performance measure set has been reduced to 300 or more live births per year.
  • Accredited hospitals and critical access hospitals will have the flexibility of continuing to meet their ORYX measure reporting requirements through one of three options:
  • Option 1 – vendor submission of quarterly data on six of nine sets of chart-abstracted measures
  • Option 2 – vendor submission of data on six of the eight sets of electronic clinical quality measures (eCQMs) (Not all vendors will qualify. See Note in 2016 ORYX Performance Measure Reporting Options document)
  • Option 3 – vendor submission of data on six sets of measures using a combination of chart-abstracted measure sets and eCQM measure sets. (Not all vendors will qualify. See Note in 2016 ORYX Performance Measure Reporting Options document)

NOTE: For Joint Commission reporting purposes data must be collected and reported on all measures in a measure set whether selecting chart-abstracted or eCQM measure sets.

  • Data on the eCQM measure sets must be reported for a minimum of one calendar quarter or up to two calendar quarters and include either 3rd Quarter 2016 and/or 4th Quarter 2016 data. 3rd Quarter 2016 and/or 4th Quarter 2016 data must be received no later than February 28, 2017. These requirements and dates align with CMS specifications.
  • Having once made its selection of an option for meeting 2016 ORYX measure reporting requirements, the hospital must continue to meet its measure reporting requirements through the selected option for a minimum of calendar year 2016.
  • Reporting on 2015 measure set/measure selections must continue through calendar year 2015

For additional information see 2016 Flexible ORYX Performance Measure Reporting Options document:posted under the “Measurement” section of The Joint Commission’s website, ORYX Performance Measurement Reporting at

Updating ORYX Measure Set Selections and Reporting Options for 2016

Beginning November 1, 2015, hospitals will be required to notify The Joint Commission of their selected reporting option and measure sets on which data will be reported for 2016. We are requesting that all updates to hospital 2016 elections be completed by November 30, 2015 Further detailed instructions on updating ORYX measure set selections will be sent in early October.

For additional questions please contact Frank Zibrat at 630-792-5992 or via e-mail at .

Thank for your continued support of The Joint Commission.

Division of Accreditation and Certification Operations

The Joint Commission