Measure Information Form
Version 2020B1
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
Related Materials
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.
MothersThe 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. NewbornsThe 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 SamplingA 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).
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 |
- 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:
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 |
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:
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 |
- 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:
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 |
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.
- 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.
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.
- 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.
The PC-Newborn with Unexpected Complications in Term Newborns measure is not eligible for sampling. Report the entire PC-Newborn Population.
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