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-9-CM Principal or Other Diagnosis Code

Patients admitted to the hospital for inpatient acute care are included in the PC Mother Initial sampling group if they have: ICD-9-CM Principal or Other Diagnosis Code as defined in Appendix A, Tables 11.01, 11.02, 11.03, or 11.04, a Patient Age (Admission Date – Birthdate) >= 8 years and < 65 and a Length of Stay (Discharge Date - Admission Date) ≤ 120 days.

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.

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, 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, NO ICD-9-CM Principal or Other Diagnosis Code as defined in Appendix A, Table 11.21 and NO ICD-9-CM-Principal or Other Procedure 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

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:

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:

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:

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:

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 100 cases for the quarter .

Monthly Sampling • A hospital’s Mother Population size is 56 patients during March. The required sample size would be 25 cases for the month.

• A hospital’s Newborns with Breast Feeding sampling group size is 254 newborns during September. The required sample size is 37 cases from the newborn sampling group for the month.