Perinatal Care (PC)

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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-10-PCS Principal or Other Procedure Code

Patients admitted to the hospital for inpatient acute care are included in the PC Mother Initial sampling group if they have: ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 11.01.1, a Patient Age (Admission Date — Birthdate) >= 8 years and < 65 and a Length of Stay (Discharge Date - Admission Date) ≤ 120 days.

Note: Hospitals are NOT required to sample their data. If sampling offers minimal benefit (e.g., a hospital has 80 cases for the quarter and must select a sample of 76 cases), or if the hospital has access to a data source which makes medical record review unnecessary (e.g., using vital records, delivery logs or clinical information systems as a data source for some of the maternal measures in the perinatal measure set), the hospital may choose to use all cases.

Newborns
The population of the PC-Newborn measures (PC-04, 05 and PC-06) are identified using 6 data elements:

• Admission Date
• Birthdate
• Discharge Date
• ICD-10-CM Principal or Other Diagnosis Code
• ICD-10-PCS Principal or Other Procedure Code
• Birth Weight

Within the PC-Newborn population, there are three subpopulations, i.e Newborns with Blood Stream Infection or BSI, Newborns with Breast Feeding, and Newborns with Unexpected Complications, 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 any one or two or three 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
PC-06	The count of all patients in PC-Newborns with Unexpected Complications

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 #3.

1. NO ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 11.10.2,
2. ONE of the following:
   • an ICD-10-CM Other Diagnosis Code as defined in Appendix A, Tables 11.12, 11.13, 11.14 Or Birth Weight >= 500g and <= 1499g
   • an ICD-10-CM Other Diagnosis Code as defined in Appendix A, Tables 11.15, 11.16, Or Birth Weight >=1500g with ANY OF THE FOLLOWING:
     • an ICD-10-PCS-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-10-CM Principal Diagnosis Code as defined in Appendix A, Table 11.10.3
   • Birth Weight Missing or Unable To Determine (UTD).
3. NO ICD-10-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-10-CM Principal Diagnosis Code as defined in Appendix A, Table 11.20.1, NO ICD-10-CM Other Diagnosis Codes as defined in Appendix A, Table 11.21, NO ICD-10-PCS-Principal or Other Procedure Code as defined in Appendix A, Table 11.22 are included in this subpopulation and are eligible to be sampled.

Newborns with Unexpected Complications - Patient Age at admission (Admission Date — Birthdate) =0 days, an ICD-10-CM Principal or other Diagnosis Code as defined in Appendix A, Table 11.20.1, and No ICD-10-CM Other Diagnosis Codes as defined in Appendix A, Table 11.12, 11.13, 11.14, 11.15, 11.16, 11.20 are included in this subpopulation.

There is NO sampling for this measure.

Note: Hospitals are encouraged to utilize a data source that reduces unnecessary medical record review e.g., using vital records, delivery logs or clinical information systems as a data source.

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Initial Patient Population Algorithm

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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.

A hospital may choose to use vital records to identify the PC-Mother Initial Patient Population as given in the Population section earlier. If a hospital uses this method to identify the initial patient population, then the hospital is encouraged to submit all the records of the initial population rather than using sampling to identify the cases for submission. Submitting all the initial patient population provides a more precise estimate of the performance rate for the measures.

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 three subpopulations each identified by Patient Age at admission and a specific group of diagnosis and procedure codes or lack thereof:

• The Newborns with BSI population and PC-Newborns with Unexpected Complications population are not eligible for sampling. Report the entire Newborns with BSI Initial Patient Population group, and the entire PC-Newborns with Unexpected Complications Initial Patient Population group 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 three sampling groups each identified by Patient Age at admission and a specific group of diagnosis codes, or lack there of:

• The Newborns with BSI population and PC-Newborns with Unexpected Complications population are not eligible for sampling. Report the entire Newborns with BSI Initial Patient Population group, and the entire PC-Newborns with Unexpected Complications Initial Patient Population group 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, cases falling in the Newborns with Breast Feeding subpopulation ONLY will flow through the PC-05 measure only and cases falling in the Newborns with Unexpected Complications subpopulation ONLY will flow through the PC-06 measure. Cases may fall in all three subpopulations and in such scenarios will be processed through all three 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 and Unexpected Complications
The Newborns with BSI population and PC-Newborns with Unexpected Complications population are not eligible for sampling. Report the entire Newborns with BSI Initial Patient Population group, and the entire PC-Newborns with Unexpected Complications Initial Patient Population 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 and Unexpected Complications
The Newborns with BSI population and PC-Newborns with Unexpected Complications population are not eligible for sampling. Report the entire Newborns with BSI Initial Patient Population group, and the entire PC-Newborns with Unexpected Complications Initial Patient Population group for reporting.