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Measure Information Form
Version 2010A


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
Admission Date All Records,
Birthdate All Records,
Clinical Trial All Records,
Discharge Date All Records, Not collected for HBIPS-2 and HBIPS-3
Discharge Status All Records, Not collected for HBIPS-2 and HBIPS-3; Used in algorithm for PC-04 and PC-05
ICD-9-CM Other Diagnosis Codes All Records, Optional for HBIPS-2 and HBIPS-3; Used in algorithm for PC-01, 02, 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 Records
ICD-9-CM Principal Diagnosis Code All Records, Optional for HBIPS-2 and HBIPS-3; Used in algorithm for PC-01, 02, 04, and 05
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 Records
Payment Source All Records, Optional for HBIPS-2 and HBIPS-3
Point of Origin for Admission or Visit All Records, Optional for HBIPS-2, HBIPS-3; Used in algorithm for PC-04
Sex All Records,

Algorithm Output Data Elements

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

Measure Set Specific Data Elements

Element Name Collected For
Active Labor PC-01,
Admission Type PC-04, PC-05,
Antenatal Steroid Administered PC-03,
Birth Weight PC-04,
Discharge from NICU PC-05,
Exclusive Breast Milk Feeding PC-05,
Gestational Age PC-01, PC-02, PC-03,
Parity PC-02,
Reason for Not Administering Antenatal Steroid PC-03,
Reason for Not Exclusively Feeding Breast Milk PC-05,
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  
a1. 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 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

Newborns
The population of the PC-Newborn measure (PC-04 and 05) are identified using 4 data elements:

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

Within the PC-Newborn population, there are two 2 sampling groups each identified by Patient Age at admission and a specific group of diagnosis codes, or lack there of. The patients in each sampling group are counted in the Initial Patient Population of multiple measures.

Measures Initial Patient Population definition
PC-04 The count of all patients in sampling group 1
PC-05 The count of all patients in sampling group 2

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

  1. Newborns with Blood Stream Infection or BSI - Patients with a Newborn Patient Age at admission (Admission Date – Birthdate) < 2 days, Length of Stay (Discharge Date - Admission Date) <= 120 days, an ICD-9-CM Other Diagnosis Code of Septicemia/Bacteremia on Appendix A Table 11.10 and NO ICD-9-CM Principal Diagnosis Code as defined in Appendix A, Table 11.10 and NO ICD-9-CM Other Diagnosis Code as defined in Appendix A, Table 11.20. There is NO sampling for this measure.
  2. Newborns with Breast Feeding - Patient Age at admission (Admission Date – Birthdate) < 2 days, Length of Stay (Discharge Date - Admission Date) <= 120 days and NO ICD-9-CM Principal or Other Diagnosis Code as defined in Appendix A, Table 11.22 are included in this sampling group and are eligible to be sampled.


Initial Patient Population Algorithm

PC_Initial_Patient_Pop_Page1.jpg


PC_Initial_Patient_Pop_Page2.jpg

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 the Newborn population.

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 for Mothers

Hospital's Measure
Average Quarterly
Initial Patient
Sample Group Size
“N”
Minimum Required
Sampling Group Sample Size
“n”
>= 2001 401
501 – 2000 20% of the Initial Patient Population size
100 – 500 100
< 100 No sampling; 100% of the Initial Patient Population required

Within the PC-Newborn population, there are two 2 sampling groups each identified by Patient Age at admission and a specific group of diagnosis codes, or lack there of:

  • The Liveborn and Transferred in Newborns sampling group is not eligible for sampling and will use the entire Newborn Initial Patient Population for reporting.
  • Hospitals selecting sample cases for the Liveborn Newborns sampling group must ensure that the Initial Patient Population and sample size for this sampling group meets the following conditions:

Newborn Patient Sampling Group

Hospital's Measure
Average Quarterly
Initial Patient
Population Size
“N”
Minimum Required
Sample Size
“n”
>= 721 145
181 – 720 20% of the Initial Patient Population size
36 – 180 36
< 36 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
Population Size
“N”
Minimum Required
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 Newborns with BSI sampling group is not eligible for sampling and will use the entire Newborn Initial Patient Population for reporting.
  • Hospitals selecting sample cases for the Newborns with Breast Feeding sampling group must ensure that the Initial Patient Population and sample size for this sampling group meets the following conditions:

Newborn Patient Sampling Group

Hospital's Measure
Average Monthly
Initial Patient
Population Size
“N”
Minimum Required
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: All sampled sampling groups in PC should be used in the calculation of all PC 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

  • A hospital’s Mother Population size is 347 during the second quarter. The required sample size is 20% of the patient population or 70 cases for the quarter (twenty percent of 347 equals 69.4 rounded up to the next highest whole number is 70).

Monthly Sampling

  • A hospital’s Mother Population size is 56 patients during March. The required sample size would be 100% of the patient sampling group or all 56 cases for the month.
  • A hospital’s Newborns with Breast Feeding sampling group size is 254 newborns during September. The required sample size is 36 cases from the newborn sampling group for the month.

Measure Information Form PC
Specifications Manual for Joint Commission National Quality Core Measures
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)