Page Comparison

Name:

Hospital Sample Size

Aggregated For:

All Measures

Definition:

The count of the number of episodes of care (EOC) records identified for a hospital to perform data abstraction on. This count is after the appropriate sampling methodology, if any, has been applied for the specific time period. This includes both Medicare and Non-Medicare patients in this count.

If the hospital’s Quarterly Sampling Frequency = 'Not Sampling' or the measure is not eligible for sampling, the Hospital Sample Size will = the Initial Population.

Each measure / measure set’s sample size requirements are outlined in the appropriate version of the Joint Commission’s Specification Manual for Joint Commission National Quality Measures or the Center for Medicare & Medicaid Services' Hospital Outpatient Quality Reporting Specifications Manual. 

Allowable Values:

1 through 10,000,000 (whole numbers only)

Note: Given only aggregate data is being submitted, the Sample Size should not be defaulted to zero when the hospital has Five or Fewer Discharges for the quarter. The actual Hospital Sample Size and remainder of the data elements must be entered.

Edits:

• If Quarterly Sampling Frequency = "monthly" or "quarterly", then Hospital Sample Size cannot be > Initial Population.

•  If the measure is not eligible for sampling (e.g., VTE-6, HBIPS-2), the DDSP will set the Hospital Sample Size = Initial Population and the user will not be able to enter a Hospital Sample Size.

• If the user selected Quarterly Sampling Frequency = 'Not Sampling', the DDSP will require the user to enter the Hospital Sample Size and will validate that it is equal to the Initial Population.

• The Hospital Sample Size for the HBIPS measure topic (set) is derived separately for each stratum. The Overall strata’s Hospital Sample Size = the sum (Hospital Sample Size of the four age strata).

• When Quarterly Sampling Frequency = ‘Monthly’, a Warning Message will be generated if the Hospital Sample Size does not adhere to the monthly sample size requirements for the measure outlined in the appropriate version of the Joint Commission’s Specification Manual for Joint Commission National Quality Measures.

• When Quarterly Sampling Frequency = ‘Quarterly’ or ‘Sampling’, a Warning Message will be generated if the sum of the Hospital Sample Size for the 3 months in the quarter does not adhere to the quarterly sample size requirements for the measure outlined in the appropriate version of the Joint Commission’s Specification Manual for Joint Commission National Quality Measures or the Center for Medicare & Medicaid Services' Hospital Outpatient Quality Reporting Specifications Manual.

Name:

Initial Population

Aggregated For:

All Measures

Definition:

This is the count of the number of episodes of care (EOC) records identified for a hospital prior to the application of data integrity filters, measure exclusions, and/or sampling methodology for the specified time period.

This data element is based on the hospital's initial identification of records for a measure set, stratum, or sub-population and includes both Medicare and Non-Medicare patients in this count.

Each measure’s initial patient population requirements are outlined in the appropriate version of the specification manual.

Note:

• HBIPS-2 and 3:  The Initial Population is different for these two measures as it is calculated as the Census Days for the hospital or unit.

Initial Population = (Psychiatric Inpatient Days - Leave Days), submitted as Days

• If the hospital's data has been sampled, this field contains the population from which the sample was originally drawn, NOT the sample size.

• Initial Population must contain the actual number of patients in the population even if the hospital has five or fewer discharges (both Medicare and non-Medicare combined) in a quarter.

Allowable Values:

0 through 10,000,000 (whole numbers only)

Note:  Hospitals entering a zero for this data element will be required to attest that they have no cases in the initial population for the measure for the month. This is to support hospitals which may not have a patient in the initial population every month and psychiatric hospitals which only provide services to children or adults. All hospitals are expected to submit data for measure applicable to the services provided and patient populations served.

Edits:

•  The Initial Population for the HBIPS measure topic (set) is derived separately for each age stratum. The Overall (e.g., HBIPS-5a) Initial Population must = the sum of the individual age strata’ Initial Population.