| Section | Rationale | Description |
|---|---|---|
| HBIPS | Updated HBIPS Initial Patient Population Algorithm and removed HBIPS-5 discharge measure related information due to retiring HBIPS-5. | Update: HBIPS Initial Patient Population Algorithm Remove: HBIPS-5 discharge measure related information. |
| PAL | Removed reference to data element sex. | Remove:
While not required for the identification of the initial patient population or the calculation of the measures,
the following data elements are collected for purposes of case identification:
|
| PC-01 | A new code table, Table 11.07.1 Early Term Gestational Age, was added to Appendix A. The guidance to use the table needs to be added to the Measure Information Form to alert abstractors to use the codes. The algorithm and narrative will also be updated to include the table. | Denominator Included Populations:
Add:
|
| PC-02 | A new code table, Table 11.10 Term Gestational Age, was added to Appendix A. The guidance to use the table needs to be added to the Measure Information Form to alert abstractors to use the codes. The algorithm and narrative are also being updated to include the table. The name of Table 11.09 was changed to Table 11.09 Multiple Gestations, Abnormal Presentations, and Conditions Justifying Cesarean Delivery due to the addition of absolute indications for cesarean section such as placenta previa, placenta accreta, placenta increta, and placenta percreta. A new reference is being added to support the addition of these exclusions. | Denominator Included Populations:
Add:
American College of Obstetricians and Gynecologists, & Society for Maternal-Fetal Medicine (2018). Obstetric Care Consensus No. 7: Placenta Accreta Spectrum. Obstetrics and gynecology, 132(6), e259–e275. |
| Section | Rationale | Description |
|---|---|---|
| Birthdate | Remove references to HBIPS-5 due to retirement of measure. | Definition Change from: * For HBIPS discharge measures, i.e., HBIPS-5, patient's age (in years) is calculated by Discharge Date minus Birthdate. For event measures, i.e., HBIPS-2, 3, patient's age at time of event (in years) is calculated by Event Date minus Birthdate. Change to: *For event measures, i.e., HBIPS-2, 3, patient's age at time of event (in years) is calculated by Event Date minus Birthdate. |
| Event Date | Remove references to HBIPS-5 due to retirement of measure. | Other Collected For Remove: Not collected for HBIPS-5 |
| Event Type | Remove references to HBIPS-5 due to retirement of measure. | Other Collected For: Remove: Not collected for HBIPS-5 |
| Gestational Age | Gestational Age code tables were added to Appendix A. Guidance on how to use the tables is being added to the Gestational Age data element. | Notes for Abstraction:
Add:
Suggested Data Sources: Add:
|
| Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade | An additional note was added to align with TICI score data collection in GWTG. | Notes for Abstraction Add:
|
| Section | Rationale | Description |
|---|---|---|
| Acknowledgement - Acknowledgment and Conditions of Use | Updated copyright date for Current Procedural Terminology (CPT®) | Change from:
The five character CPT® codes included in the Specifications Manual for Joint Commission National Quality Measures are obtained from Current Procedural Terminology (CPT®), copyright 2023 by the American Medical Association (AMA).
To: The five character CPT® codes included in the Specifications Manual for Joint Commission National Quality Measures are obtained from Current Procedural Terminology (CPT®), copyright 2024 by the American Medical Association (AMA). |
| Appendix D - Glossary of Terms | Updated the definitions for hospital-based inpatient psychiatric services (HBIPS) and subset measure(s) to align with the retirement of HBIPS measures and TOB-2. | Change from:
The Hospital-Based Inpatient Psychiatric Services (HBIPS) is a national quality partnership of organizations focused on improving quality and performance in impatient psychiatric settings through performance measurement utilizing 5 process measures in 3 separate domains (assessment, patient safety, continuity/transition of care).
To: The Hospital-Based Inpatient Psychiatric Services (HBIPS) measure set is targeted towards improving quality and performance in inpatient psychiatric settings through 2 process measures. Change from: A subset measure contains overlapping sets of patients. For example, the patients in the TOB-2a measure are a subset of those in the TOB-2 measure, i.e., the two measures have overlapping populations. To: A subset measure contains overlapping sets of patients. For example, the patients in the SUB-2a measure are a subset of those in the SUB-2 measure, i.e., the two measures have overlapping populations. |
| Data Dictionary - Introduction to the Data Dictionary | Remove (Optional for all HBIPS measures) due to retiring HBIPS-5. Remove Sex data element. Removed reference to data general data elements being submitted. | Remove: (Optional for all HBIPS measures)
Remove:
To: Regardless of which measure sets are selected by a hospital, certain general data elements must be collected by the hospital for every patient that falls into any of the selected Initial Patient Populations. These data elements are considered "general" to each patient's episode of care. These data elements include:
|
| Joint Commission Clinical Data Processing Flow - Transmission Data Processing Flow: Clinical | Removed the reference of HBIPS discharge measure from various locations due to retiring of the HBIPS-5 measure. | Change from:
Note HBIPS:
HBIPS contains two Initial Patient Populations, discharges and events. All events of the same type occurring on the same day are reported as one measure (i.e., added as total). However, different types of events occurring on the same day are reported as different measures (i.e., different numbers).
To: Note HBIPS: HBIPS contains Initial Patient Population for event measures. All events of the same type occurring on the same day are reported as one measure (i.e., added as total). However, different types of events occurring on the same day are reported as different measures (i.e., different numbers). Change from: The general data elements, as defined in the Introduction to the Data Dictionary section, should be evaluated to ensure they exist and contain valid allowable values. The HBIPS measure set is unique in that it has three different groups of general data elements. The first group is "general" for all measures in the set. The second group is only "general" for the HBIPS discharge measures. The third group is only "general" for the HBIPS event measures. In addition, HBIPS data elements may be "measure set specific" for one type of HBIPS measure and "general" for the other type. For example, Psychiatric Care Setting is a "measure set specific" data element for the discharge measures and a "general" data element for the event measures. To: The general data elements, as defined in the Introduction to the Data Dictionary section, should be evaluated to ensure they exist and contain valid allowable values. HBIPS data elements may be "measure set specific" or general. For example, Psychiatric Care Setting is a "general" data element for the event measures. |
| Sampling | Removed the reference of HBIPS discharge measure from various locations due to retiring of HBIPS-5 measure. | Remove: Reference of HBIPS discharge measures from multiple places. |
| Rationale | Description |
|---|---|
| The data element Sex is being removed pending alignment with new CMS data elements for sex and gender identity. | Remove: Sex data element in its entirety. |
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