The Joint Commission
2015 FLEXIBLE ORYX REPORTING OPTIONS
and
CORE MEASURE SET SELECTION FORM
HCO ID#
Fax Completed Forms
to
(630) 792-4992
HCO NAME
ADDRESS
CITY, STATE, ZIP
2015 ORYX REPORTING OPTIONS
Effective with January 1, 2015 discharges accredited hospitals have the flexibility of meeting their ORYX measure reporting
requirements through one of three options.
Detailed information regarding each of the available reporting options can be found in the “2015 Flexible ORYX Performance
Measure Reporting Options” document posted under the “Measurement” section of The Joint Commission’s website at
http://www.jointcommission.org/performance_measurement.aspx.
Please carefully review the options document. Once you have reviewed the 2015 options:
 Select the one best option for your hospital by checking the appropriate box below.
 Complete your minimum 6 core measure set selections for 2015 by completing the relevant page(s) that follow
o NOTE: Critical Access Hospitals are only required to select a minimum of 4 sets of measures
 Fax your completed form to 630-792-4992 or e-mail the form to fzibrat@jointcommission.org
 Provide your listed core measure vendor with a copy of this form.
2015 FLEXIBLE ORYX REPORTING OPTIONS
(Select ONE Option)
□
Option 1 – vendor submission of quarterly data on a minimum of six sets of chart-abstracted measures.
 Complete measure set selections using the CHART-ABSTRACTED MEASURE SET SELECTION
FORM
□
Option 2 – vendor submission of quarterly data on a minimum of six sets of electronic clinical quality measures
(eCQMs).
 Complete measure set selections using the eCQM MEASURE SET SELECTION FORM
□
Option 3 – vendor submission of quarterly data on a minimum of six sets of measures using a combination of chartabstracted measure sets and electronic clinical quality measures (eCQM) measure sets.
 Complete measure set selections using the CHART-ABSTRACTED MEASURE SET SELECTION
FORM and eCQM MEASURE SET SELECTION FORM as appropriate.
 Hospitals wishing to select this option and that may be interested in reporting on the same set(s) of
chart-abstracted and eCQM measure sets/measuress should contact Frank Zibrat at 630-792-5992 or
via e-mail at fzibrat@jointcommission.org
NOTE: Hospitals must continue to meet their ORYX reporting requirements through the selected option for a minimum of
calendar year 2015.
(Cont’d. on next page)
Page 1 of 4
The Joint Commission
2015 CHART-ABSTRACTED CORE MEASURE SET SELECTION FORM
HCO ID#
Fax Completed Forms
to
(630) 792-4992
HCO NAME
ADDRESS
CITY, STATE, ZIP
VENDOR SELECTED
VENDOR NAME
VENDOR ID#
DATA COLLECTION
START DATE
(If changing vendor for 2015)
________________________________________________


______________
______________
Data MUST be reported on EACH APPLICABLE MEASURE in the measure set.
Data collection must begin on the first day of a calendar quarter.
DATA COLLECTION
START DATE
(If changing measure sets for 2015)
□
AMI (AMI-7a)
________________
□
Children’s Asthma Care (CAC)
________________
□
Emergency Department (ED)
________________
□
Hospital Based Inpatient Psychiatric Services (HBIPS)
________________
 (AMI-7a) (Unavailable if you do not provide/rarely provide fibrinolytic therapy)
 (CAC-3)
 (ED-1a, ED-1b, ED-1c, ED-2a, ED-2b, ED-2c)
 (HBIPS-1, HBIPS-2, HBIPS-3, HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7)
Data collection required by free-standing Psychiatric Hospitals.
Please indicate all patient age groups your organization treats by filling in the appropriate circles.
Data must be collected and submitted for all measures and include all relevant patient age groups.
o
o
o
o
Children (1-12 years)
Adolescent (13-17 years)
Adult (18-64 years)
Geriatric (> 65 years)
□
Hospital Outpatient (HOP)
________________
□
Immunization (IMM)
________________
□
 (OP-1, OP-2, OP-3, OP-4, OP-5, OP-6, OP-7, OP-18, OP-20, OP-21, OP-23)

(IMM-2)
Perinatal Care (PC) (Required if the hospital has at least 1,100 live births per year)

________________
(PC-01, PC-02, PC-03, PC-04, PC-05/5a)
□
Stroke (STK)
________________
□
Substance Use (SUB)
________________
□
Surgical Care Improvement Project (SCIP)
________________
□
Tobacco Treatment (TOB)
□
 (STK-1, STK-2, STK-3, STK-4, STK-5, STK-6, STK-8, STK-10)
 (SUB-1, SUB-2, SUB-3)
 (SCIP-INF-4) (Unavailable if you do not perform CABG or Other Cardiac Surgery procedures)

Venous Thromboembolism (VTE)

________________
(TOB-1, TOB-2, TOB-3)
________________
(VTE-1, VTE-2, VTE-3, VTE-5, VTE-6)
(Cont’d. on next page)
Page 2 of 4
The Joint Commission
2015 eCQM (Electronic Clinical Quality Measures)
CORE MEASURE SET SELECTION FORM
HCO ID#
HCO NAME
ADDRESS
CITY, STATE, ZIP
Fax Completed Forms
to
(630) 792-4992
VENDOR SELECTED
VENDOR NAME
VENDOR ID#
DATA COLLECTION
START DATE
(If changing vendor for 2015)
________________________________________________



______________
______________
Data MUST be reported on EACH APPLICABLE MEASURE in the measure set.
Data collection must begin on the first day of a calendar quarter.
For each measure set, circle the calendar quarter(s) for which you will report eMeasure data by 12/15/2015.
2015
CALANDAR QUARTER(s)
DATA to be SUBMITTED
□
AMI (AMI-7a)
1Q15 2Q15
3Q15
□
Children’s Asthma Care (CAC)
1Q15
2Q15
3Q15
□
Emergency Department (ED)
1Q15
2Q15
3Q15
□
Perinatal Care (PC) (Required if the hospital has at least 1,100 live births per year)
1Q15
2Q15
3Q15
 (eAMI-7a) (Unavailable if you do not provide/rarely provide fibrinolytic therapy)
 (eCAC-3)
 (eED-1a, eED-2a)

(ePC-01, ePC-05/5a)
□
Stroke (STK)
1Q15
2Q15
3Q15
□
Surgical Care Improvement Project (SCIP)
1Q15
2Q15
3Q15
□
Venous Thromboembolism (VTE)
1Q15
2Q15
3Q15
 (eSTK-2, eSTK-3, eSTK-4, eSTK-5, eSTK-6, eSTK-8, eSTK-10)
 (eSCIP-INF-1, eSCIP-INF-1-1, eSCIP-INF-1-2, eSCIP-INF-1-3, eSCIP-INF-1-4,
eSCIP-INF-1-5, eSCIP-INF-1-6, eSCIP-INF-1-7, eSCIP-INF-1-8, eSCIP-INF-9)

(eVTE-1, eVTE-2, eVTE-3, eVTE-4, eVTE-5, eVTE-6)
NOTE:
1. For submission of 2015 discharge data, The Joint Commission will only accept data consistent with the April 2014
eCQM specifications posted on the CMS website:
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html ).
2. A listed ORYX eMeasure Vendor’s technology must be certified by an Office of the National Coordinator for Health
Information Technology Authorized Certification Body (ONC-ACB) as meeting the 2014 Edition certification criteria
for calculating and submitting inpatient electronic clinical quality measures (eCQMs).
3. If your organization is seeking or is currently Joint Commission certified as a Primary Stroke Center or
Comprehensive Stroke Center, data must continue to be reported on all The Joint Commission chart-abstracted
Stroke measures.
(Cont’d. on next page)
Page 3 of 4
The Joint Commission
2015 FLEXIBLE ORYX REPORTING OPTIONS
and
CORE MEASURE SET SELECTION FORM
SIGNATURE PAGE
HCO ID#
HCO NAME
ADDRESS
CITY, STATE, ZIP
Fax Completed Forms
to
(630) 792-4992
Joint Commission policy requires that your organization provide written confirmation of the performance measurement
system(s) and performance measures your organization has selected to meet performance measurement requirements for
accreditation. Please:
 Review the form to be certain that you have selected a reporting option
 Be certain that you have indicated the measure sets on which you will be reporting data
 Sign the selection form below
 Fax the completed form to 630-792-4992 or e-mail the form to fzibrat@jointcommission.org
 Provide your listed core measure vendor with a copy of this form
___________________________________
__________________________________
_______________
Primary Contact
Phone
Date
___________________________________
__________________________________
_______________
Chief Executive Officer
Signature
Date
Page 4 of 4
List of Chart-Abstracted Measures
Measure
Measure Name
Label
AMI-7a
CAC-3
ED-1a
ED-1b
ED-1c
ED-2a
ED-2b
ED-2c
HBIPS-1
HBIPS-2
HBIPS-3
HBIPS-4
HBIPS-5
HBIPS-6
HBIPS-7
OP-1
OP-2
OP-3
OP-4
OP-5
OP-6
OP-7
OP-18
OP-20
OP-21
OP-23
IMM-2
PC-1
PC-2
PC-3
PC-4
PC-5/5a
STK-1
STK-2
STK-3
STK-4
STK-5
STK-6
STK-8
STK-10
SUB-1
SUB-2
SUB-3
SCIPINF-4
TOB-1
TOB-2
TOB-3
VTE-1
VTE-2
VTE-3
VTE-5
VTE-6
Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
Median Time from ED Arrival to ED Departure for Admitted ED Patients-Overall Rate
Median Time from ED Arrival to ED Departure for Admitted ED Patients-Reporting Measure
Median Time from ED Arrival to ED Departure for Admitted ED Patients- Psychiatric/Mental Health Patients
Admit Decision Time to ED Departure Time for Admitted Patients-Overarll Rate
Admit Decision Time to ED Departure Time for Admitted Patients-Reporting Measure
Admit Decision Time to ED Departure Time for Admitted Patients-Psychiatric/Mental Health Patients
Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient
Strengths completed
Hours of physical restraint use
Hours of seclusion use
Patients discharged on multiple antipsychotic medications
Patients discharged on multiple antipsychotic medications with appropriate justification
Post discharge continuing care plan created
Post discharge continuing care plan transmitted to next level of care provider upon discharge
Median time to fibrinolysis
Fibrinolytic therapy received within 30 minutes
Median time to transfer to another facility for acute coronary Intervention
Aspirin at arrival
Median time to ECG
Timing of antibiotic prophylaxis
Prophylactic antibiotic selection for surgical patients
Median time from ED arrival to ED departure for discharged ED patients
Door to diagnostic evaluation by a qualified medical professional
ED-Median time to pain management for long bone fracture
ED-Head CT scan results for acute ischemic stroke or hemorrhagic stroke who received head CT scan
interpretation within 45 minutes of arrival
Influenza Immunization
Elective Delivery
Cesarean Section
Antenatal Steroids
Health Care-Associated Bloodstream Infections in Newborns
Exclusive Breast Milk Feeding
Venous Thromboembolism (VTE) Prophylaxis
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Thrombolytic Therapy
Antithrombotic Therapy By End of Hospital Day 2
Discharged on Statin Medication
Stroke Education
Assessed for Rehabilitation
Alcohol Use Screening
Alcohol Use Brief Intervention Provided or Offered
Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge
Cardiac Surgery Patients With Controlled Postoperative Blood Glucose
Tobacco Use Screening
Tobacco Use Treatment Provided or Offered
Tobacco Use Treatment Provided or Offered at Discharge
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis
Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
Venous Thromboembolism Warfarin Therapy Discharge Instructions
Hospital Acquired Potentially-Preventable Venous Thromboembolism
List of Electronic Clinical Quality Measures (eMeasures/eCQMs)
Measure
Label
eAMI-7a
eCAC-3
eED-1a
eED-1b
eED-1c
eED-2a
eED-2b
eED-2c
ePC-1
ePC-5/5a
eSTK-2
eSTK-3
eSTK-4
eSTK-5
eSTK-6
eSTK-8
eSTK-10
eSCIP-Inf-1
eSCIP-Inf-1-1
eSCIP-Inf-1-2
eSCIP-Inf-1-3
eSCIP-Inf-1-4
eSCIP-Inf-1-5
eSCIP-Inf-1-6
eSCIP-Inf-1-7
eSCIP-Inf-1-8
eSCIP-Inf-9
eVTE-1
eVTE-2
eVTE-3
eVTE-4
eVTE-5
eVTE-6
Measure Name
Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
Median Time from ED Arrival to ED Departure for Admitted ED Patients-Overall Rate
Median Time from ED Arrival to ED Departure for Admitted ED Patients-Reporting Measure
Median Time from ED Arrival to ED Departure for Admitted ED Patients- Psychiatric/Mental Health
Patients
Admit Decision Time to ED Departure Time for Admitted Patients-Overarll Rate
Admit Decision Time to ED Departure Time for Admitted Patients-Reporting Measure
Admit Decision Time to ED Departure Time for Admitted Patients-Psychiatric/Mental Health Patients
Elective Delivery
Exclusive Breast Milk Feeding
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Thrombolytic Therapy
Antithrombotic Therapy By End of Hospital Day 2
Discharged on Statin Medication
Stroke Education
Assessed for Rehabilitation
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Overall Rate
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - CABG
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Other Cardiac Surgery
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hip Arthroplasty
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Knee Arthroplasty
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Colon Surgery
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision – Abdominal Hysterectomy
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Vaginal Hysterectomy
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Vascular Surgery
Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of
surgery being day zero
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis
Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count
Monitoring by Protocol or Nomogram
Venous Thromboembolism Warfarin Therapy Discharge Instructions
Hospital Acquired Potentially-Preventable Venous Thromboembolism