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Measure Information Form
Version 2013A1


Perinatal Care (PC)

Set Measures

Set Measure ID Measure Short Name
PC-01 Elective Delivery
PC-02 Cesarean Section
PC-03 Antenatal Steroids
PC-04 Health Care-Associated Bloodstream Infections in Newborns
PC-05 Exclusive Breast Milk Feeding

General Data Elements

Element Name Collected For
Birthdate All Records,
CMS Certification Number Hospital Clinical Data File, Optional for All Records,
Clinical Trial All Records,
Discharge Date All Records, Not collected for HBIPS-2 and HBIPS-3
Health Care Organization Identifier All Records, Aggregate Data File, Patient Population Data File, Hospital Clinical Data File,
Hispanic Ethnicity All Records,
ICD-9-CM Other Diagnosis Codes All Records, Optional for HBIPS-2, HBIPS-3 and PBM; Used in algorithm for PC-01, 02, 03, 04, and 05
ICD-9-CM Other Procedure Codes All Records, Optional for All HBIPS Records; Used in algorithm for PC-01, 02, 04 and 05;
ICD-9-CM Other Procedure Dates All Records, Optional for All HBIPS and PBM Records
ICD-9-CM Principal Diagnosis Code All Records, Optional for HBIPS-2 and HBIPS-3; Used in algorithm for PC-01, 02, 03, 04, 05 and PBM-03
ICD-9-CM Principal Procedure Code All Records, Optional for All HBIPS Records; Used in algorithm for PC-01, 02, 04 and 05
ICD-9-CM Principal Procedure Date All Records, Optional for All HBIPS and PBM Records
Payment Source All Records, Optional for HBIPS-2 and HBIPS-3
Race All Records,
Sex All Records,

Algorithm Output Data Elements

Element Name Collected For
Measure Category Assignment Calculation, Transmission, Hospital Clinical Data File

Measure Set Specific Data Elements

Element Name Collected For
Admission Date PC,
Admission to NICU PC-05,
Antenatal Steroid Therapy Initiated PC-03,
Birth Weight PC-04,
Discharge Disposition PC-04, PC-05,
Exclusive Breast Milk Feeding PC-05,
Gestational Age PC-01, PC-02, PC-03,
Labor PC-01,
Parity PC-02,
Prior Uterine Surgery PC-01,
Reason for Not Exclusively Feeding Breast Milk PC-05,
Reason for Not Initiating Antenatal Steroid Therapy PC-03,
Spontaneous Rupture of Membranes PC-01,


Related Materials

  Document Name  
a. Cover page for the Joint Commission Manual  
a. Table of Contents  
a1. Acknowledgment and Conditions of Use  
a2. Introduction to the Manual  
a3. Using the The Joint Commission's National Measure Specifications Manual  
b. Data Dictionary  
d. Missing and Invalid Data  
e. Sampling  
g1. Transmission of Data  
g2. Transmission Alpha Data Dictionary  
g3. Transmission Data Processing Flow: Clinical  
g4. Transmission Data Processing Flow: Population and Sampling  
z. Appendix A - ICD-9-CM Code Tables  
z. Appendix A Addendum  
z. Appendix B - Medication Tables  
z. Appendix C - Glossary of Terms  
z. Appendix D - Overview of Measure Information Form and Flowchart Formats  
z. Appendix E - Miscellaneous Tables  
z. Appendix F - Resources  

Perinatal Care (PC) Initial Patient Population

The PC measure set is unique in that there are two distinct Initial Patient Populations within the measure set, mothers and newborns.

Mothers
The population of the PC-Mother measures (PC-01, 02, and 03) are identified using 4 data elements:

  • Admission Date
  • Birthdate
  • Discharge Date
  • ICD-9-CM Principal or Other Diagnosis Code

Patients admitted to the hospital for inpatient acute care are included in the PC Mother Initial sampling group if they have: ICD-9-CM Principal or Other Diagnosis Code as defined in Appendix A, Tables 11.01, 11.02, 11.03, or 11.04, a Patient Age (Admission Date – Birthdate) >= 8 years and < 65 and a Length of Stay (Discharge Date - Admission Date) ≤ 120 days.

Newborns
The population of the PC-Newborn measure (PC-04 and 05) are identified using 5 data elements:

  • Admission Date
  • Birthdate
  • Discharge Date (PC-05 only)
  • ICD-9-CM Principal or Other Diagnosis Code
  • ICD-9-CM Principal or Other Procedure Code

Within the PC-Newborn population, there are two 2 subpopulations, i.e Newborns with Blood Stream Infection or BSI, Newborns with Breast Feeding, each identified by Patient Age at admission and a specific group of diagnosis and procedure codes or lack thereof. The patients in each subpopulation are processed independently through each initial patient population flow. Patients may fall in both subpopulations depending on the presence or absence of the diagnosis codes or procedure codes and other data elements defined by the respective initial patient subpopulations.

Measures Initial Patient Population definition
PC-04 The count of all patients in PC-Newborns with BSI
PC-05 The count of all patients in PC-Newborns with Breast Feeding

Patients admitted to the hospital for inpatient acute care are included in one of the PC Newborn subpopulations if they have:

Newborns with BSI - Patients with a Newborn Patient Age at admission (Admission Date – Birthdate) ≤ 2 days AND satisfy conditions#1 through #4.

  1. NO ICD-9-CM Principal Diagnosis Code as defined in Appendix A, Table 11.10.2,
  2. NO ICD-9-CM Principal Diagnosis Code as defined in Appendix A, Table 11.10.3 AND NO ICD-9-CM Other Diagnosis Code as defined in Appendix A, Table 11.10
  3. ONE of the following:
    • an ICD-9-CM Other Diagnosis Code as defined in Appendix A, Tables 11.12, 11.13, 11.13.1, 11.14 Or Birth Weight >= 500g and <= 1499g
    • an ICD-9-CM Other Diagnosis Code as defined in Appendix A, Tables 11.15, 11.16, 11.16.1, 11.17 Or Birth Weight >=1500g with ANY OF THE FOLLOWING:
      • an ICD-9-CM-Principal or Other Procedure Code as defined in Appendix A, Tables 11.18 or 11.19
      • Discharge Disposition of 6 (expired) or a Missing Discharge Disposition
      • NO ICD-9-CM Principal Diagnosis Code as defined in Appendix A, Table 11.10.3
    • Birth Weight Missing or Unable To Determine (UTD).
  4. NO ICD-9-CM Other Diagnosis Code as defined in Appendix A, Table 11.20 Or Birth Weight < 500g

There is NO sampling for this measure.

Newborns with Breast Feeding - Patient Age at admission (Admission Date – Birthdate) ≤ 2 days, Length of Stay (Discharge Date - Admission Date) ≤ 120 days, an ICD-9-CM Principal as defined in Appendix A, Table 11.20.1, NO ICD-9-CM Other Diagnosis Codes as defined in Appendix A, Table 11.21, NO ICD-9-CM-Principal or Other Procedure Code as defined in Appendix A, Table 11.22 and NO ICD-9-CM Other Diagnosis Codes as defined in Appendix A, Table 11.23 are included in this subpopulation and are eligible to be sampled.


Initial Patient Population Algorithm

PC_Initial_Patient_Pop_Page1.jpg v8

PC_Initial_Patient_Pop_Page2.jpg v10

PC_Initial_Patient_Pop_Page3.jpg v8


Sample Size Requirements

Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may choose to use a larger sample size than is required. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter/month for the sampling group cannot sample that sampling group. Hospitals that have five or fewer discharges for the three combined PC sampling groups (both Medicare and non-Medicare combined) in a quarter are not required to submit PC patient level data to the Joint Commission’s Data Warehouse.

Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. Due to exclusions and contraindications, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size.

The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual.

Quarterly Sampling
A modified sampling procedure is required for hospitals performing quarterly sampling for PC. Hospitals selecting sample cases must ensure that each individual sampling group Initial Patient Population and sample size meet the following conditions:

  • Select within the two individual measure sampling groups (mothers and babies).
  • Select independently from each of the Newborn subpopulation.

Hospitals selecting sample cases for the PC-Mothers must ensure that the Initial Patient Population and sample size for this PC sampling group meets the following conditions:

Quarterly Sample Size
Based on Initial Patient Population for Mothers

Hospital's Measure
Average Quarterly
Initial Patient
Sample Group Size
“N”
Minimum Required
Sampling Group Sample Size
“n”
>= 1501 301
376 – 1500 20% of the Initial Patient Population size
75 – 375 75
< 75 No sampling; 100% of the Initial Patient Population required

Within the PC-Newborn population, there are two subpopulations each identified by Patient Age at admission and a specific group of diagnosis and procedure codes or lack thereof:

  • The PC-Newborns with BSI subpopulation is not eligible for sampling and will use the entire Newborns with BSI Initial Patient subpopulation for reporting.
  • Hospitals sampling for the PC-Newborns with Breast Feeding must ensure the sample size calculations should be based on the newborns with breast feed subpopulation count ONLY. Hospitals selecting cases for the PC-Newborns with Breastfeeding must ensure that the patient population size for this subpopulation meets the following conditions:

Quarterly Sample Size Based on Initial Patient Population for PC-Newborns with Breastfeeding

Hospital's Measure
Average Quarterly
Initial Patient
Sample Group Size
“N”
Minimum Required
Sample Size
“n”
>= 541 109
136 – 540 20% of the Initial Patient Population size
27 – 135 27
< 27 No sampling; 100% of Initial Patient Population required

Monthly Sampling
Hospitals selecting sample cases for the Mothers must ensure that the Initial Patient Population and sample size for this sampling group meets the following conditions:

Monthly Sample Size
Based on Initial Patient Population for Mothers

Hospital's Measure
Average Monthly
Initial Patient
Sample Group Size
“N”
Minimum Required Sampling Group
Sample Size
“n”
>= 501 101
126 – 500 20% of the Initial Patient Population
25 – 125 25
< 25 No sampling; 100% Initial Patient Population required

Within the PC-Newborn population, there are two sampling groups each identified by Patient Age at admission and a specific group of diagnosis codes, or lack there of:

  • The PC-Newborns with BSI subpopulation is not eligible for sampling and will use the entire Newborns with BSI Initial Patient subpopulation for reporting.
  • Hospitals sampling for the PC-Newborns with Breast Feeding must ensure the sample size calculations should be based on the newborns with breast feed subpopulation count ONLY. Hospitals selecting cases for the PC-Newborns with Breastfeeding must ensure that the patient population size for this subpopulation meets the following conditions:

Monthly Sample Size Based on Initial Patient Population for Newborns with Breast Feeding

Hospital's Measure
Average Monthly
Initial Patient
Sample Group Size
“N”
Minimum Required Sampling Group
Sample Size
“n”
>= 181 37
46 – 180 20% of the Initial Patient Population
9 – 45 9
< 9 No sampling; 100% Initial Patient Population required

Sample Size Examples
Note: PC-Mothers: All sampling groups in PC-Mother population should be used in the calculation of all PC-Mother measures. All of the PC measures' specific exclusion criteria are used to filter out cases that do not belong in the measure denominator. PC-Newborns: Cases falling within each newborns subpopulation should be run through the respective Newborn measures only. Cases falling in the Newborns with BSI subpopulation ONLY will flow through the PC-04 measure and cases falling in the Newborns with Breast Feeding subpopulation ONLY will flow through the PC-05 measure only. Cases may fall in both subpopulations and in such scenarios will be processed through both measures. It should be noted that cases should be processed independently through each of newborn initial subpopulation flows to obtain cases for sampling and abstraction.

Quarterly Sampling
Mother Population

  • A hospital’s Mother Population size is 2300 cases during the second quarter. Using the quarterly sampling table for the Mother population, the sample size required is 301 cases for the quarter.
  • A hospital’s Mother Population size is 1500 cases during the second quarter. Using the quarterly sampling table for the Mother population, the sample size required is 20% of this sub-population or 300 cases for the quarter.
  • A hospital’s Mother Population size is 300 cases during the second quarter. Using the quarterly sampling table for the Mother population, the sample size required 75 cases for the quarter.
  • A hospital’s Mother Population size is 72 cases during the second quarter. Using the quarterly sampling table for the Mother population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population or all 72 cases are sampled.

Newborns with Breast Feeding

  • A hospital’s Newborns with Breast Feeding Population size is 600 cases during the second quarter. Using the quarterly sampling table for the Newborns with Breast Feeding population, the sample size required is 109 cases.
  • A hospital’s Newborns with Breast Feeding Population size is 350 cases during the second quarter. Using the quarterly sampling table for the Newborns with Breast Feeding population, the sample size required is 20% of this sub-population or 70 cases for the quarter .
  • A hospital’s Newborns with Breast Feeding Population size is 99 cases during the second quarter. Using the quarterly sampling table for the Newborns with Breast Feeding population, the sample size required 27 cases for the quarter.
  • A hospital’s Newborns with Breast Feeding Population size is 25 cases during the second quarter. Using the quarterly sampling table for the Newborns with Breast Feeding population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population or all 25 cases are sampled.

Newborns with BSI The Newborns with BSI population is not eligible for sampling and will use the entire Newborns with BSI Initial Patient sampling group for reporting.

Monthly Sampling
Mother Population

  • A hospital’s Mother Population size is 510 cases during March. Using the monthly sampling table for the Mother population, the sample size required is 101 cases for the month.
  • A hospital’s Mother Population size is 400 cases during March. Using the monthly sampling table for the Mother population, the sample size required is 20% of this sub-population or 80 cases for the month.
  • A hospital’s Mother Population size is 125 cases during March. Using the monthly sampling table for the Mother population, the sample size required is 25 cases for the month.
  • A hospital’s Mother Population size is 20 cases during March. Using the quarterly sampling table for the Mothers population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population or all 20 cases are sampled.

Newborns with Breast Feeding

  • A hospital’s Newborns with Breast Feeding Population size is 200 cases for the month of March. Using the monthly sampling table for the Newborns with Breast Feeding population, the sample size required is 37 cases.
  • A hospital’s Newborns with Breast Feeding Population size is 100 cases for the month of March. Using the monthly sampling table for the Newborns with Breast Feeding population, the sample size required is 20% of this sub-population or 20 cases for the month.
  • A hospital’s Newborns with Breast Feeding Population size is 30 cases for the month of March. Using the monthly sampling table for the Newborns with Breast Feeding population, the sample size required 9 cases for the month.
  • A hospital’s Newborns with Breast Feeding Population size is 8 cases during the second quarter. Using the monthly sampling table for the Newborns with Breast Feeding population, the sample size is less than the minimum required monthly sample size, so 100% of this sub-population or all 8 cases are sampled.

Newborns with BSI The Newborns with BSI population is not eligible for sampling and will use the entire Newborns with BSI Initial Patient sampling group for reporting.

Measure Information Form PC
Specifications Manual for Joint Commission National Quality Measures (v2013A1)
Discharges 01-01-13 (1Q13) through 06-30-13 (2Q13)