Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020

Home » Perinatal Care (PC)

Release Notes:
Measure Information Form
Version 2020B


Perinatal Care (PC)

Set Measures

Set Measure ID Measure Short Name
PC-01 Elective Delivery
PC-02 Cesarean Birth
PC-05 Exclusive Breast Milk Feeding
PC-06 Unexpected Complications in Term Newborns

General Data Elements

Element Name Collected For
Admission Date All Records,
Birthdate All Records,
Discharge Date All Records, Not collected for HBIPS-2 and HBIPS-3
Hispanic Ethnicity All Records,
ICD-10-CM Other Diagnosis Codes All Records, Optional for HBIPS-2, HBIPS-3
ICD-10-CM Principal Diagnosis Code All Records, Optional for HBIPS-2, HBIPS-3
ICD-10-PCS Other Procedure Codes All Records, Optional for All HBIPS Records
ICD-10-PCS Other Procedure Dates All Records, Optional for All HBIPS Records
ICD-10-PCS Principal Procedure Code All Records, Optional for All HBIPS Records
ICD-10-PCS Principal Procedure Date All Records, Optional for All HBIPS Records
Measure Category Assignment All Records, Calculation, Used in calculation of the Joint Commission's aggregate data.
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 All Records, Calculation
Measurement Value Calculation

Measure Set Specific Data Elements

Element Name Collected For
Admission to NICU PC-05
Birth Weight PC-06
Discharge Disposition PC-05, PC-06
Exclusive Breast Milk Feeding PC-05
Gestational Age PC-01, PC-02
History of Stillbirth PC-01
Labor PC-01
Previous Live Births PC-02
Prior Uterine Surgery PC-01
Term Newborn PC-05, PC-06


  Document Name  
Acknowledgement  
Appendix A  
Appendix C  
Appendix D - Glossary of Terms  
Appendix E - Overview of Measure Information Form and Flowchart Formats  
Appendix G - Resources  
Appendix H - Miscellaneous Tables  
Cover Page for the Joint Commission Manual  
Data Dictionary  
Introduction to the Manual  
Joint Commission National Quality Measures Data Processing  
Missing and Invalid Data  
Table of Contents  
Using the The Joint Commission's National Measure Specifications Manual  


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, and 02) 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-05, PC-06) are identified using 4 data elements:
  • Admission Date
  • Birthdate
  • Discharge Date
  • ICD-10-CM Principal or Other Diagnosis Code

Patients admitted to the hospital for inpatient acute care are included in the PC Newborn Initial population if they have: A Patient Age (Admission Date — Birthdate) <= 1 day and ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.20.1

Within the PC-Newborn population, there are two baby measures, Exclusive Breast Milk Feeding and Unexpected Complications in Term Newborns. The patients in each measure are processed independently. Patients in the newborn population always run against the Unexpected Complication in Term Newborns measure and they may run against Exclusive Breast Milk Feeding measure if sampled.

Measures Initial Patient Population definition
PC-05, 06 The count of all patients in PC-Newborn population

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.


Initial Patient Population Algorithm


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.

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 condition:
  • Select within the two individual measure sampling groups (mothers and babies).

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 baby measures Exclusive Breast Milk Feeding and Unexpected Complications in Term Newborns. All patients in this population must run against Unexpected Complications in Term Newborns measure. However, they may run against Exclusive Breast Milk Feeding measure if the patient is sampled for Exclusive Breast Milk Feeding.

  • Hospitals selecting cases for the PC-Newborn with Exclusive Breast Milk Feeding must ensure that the patient population size for this measure meets the following conditions:

Quarterly Sample Size
Based on PC-Newborn Initial Patient Population to use for Exclusive Breast Milk Feeding
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 baby measures, Exclusive Breast Milk Feeding and Unexpected Complications in Term Newborns. All patients in this population must run against Unexpected Complications in Term Newborns measure. However, they may run against Exclusive Breast Milk Feeding measure if the patient is sampled for Exclusive Breast Milk Feeding measure.

  • Hospitals sampling for the PC-Newborn with Exclusive Breast Milk Feeding must ensure that the patient population size for this subpopulation meets the following conditions:

Monthly Sample Size
Based on Initial Patient Population for Exclusive Breast Milk 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.

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.

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

PC-Newborn with Unexpected Complications In Term Newborns
The PC-Newborn with Unexpected Complications in Term Newborns population is not eligible for sampling. Report the entire PC-Newborn Population.

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.

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

PC-Newborn for with Unexpected Complications in Term Newborns
The PC-Newborn with Unexpected Complications in Term Newborns measure is not eligible for sampling. Report the entire PC-Newborn Population.

Measure Information Form PC
CPT® only copyright 2019 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2020B)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)

CPT® only copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.

^