Joint Commission Guide for Data Entry of Chart-Abstracted Measures for Hospitals (HAP/CAH)
- Version 2023: Discharges 01-01-23 (1Q2023) through 12-31-23 (4Q2023)
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Name: | Denominator |
Aggregated For: | Proportion and ratio measures |
Definition: | Summation of denominator cases (proportion) or the denominator component (ratio) for the measure's population during the month. The Denominator is the count of each patient-level record with a measure category assignment of ‘D’ or ‘E’ (i.e., [count of ‘D’ + count of ‘E’] = Denominator). Aggregate all case-level records that are members of a measure's population. Do not eliminate or suppress outliers. Note:
Denominator = (Psychiatric Inpatient Days - Leave Days), submitted as Hours |
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 denominator (i.e., ‘zero denominator’) for the measure for the month. Hospitals with denominator cases are expected to enter the appropriate value for each measure or strata. |
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Name: | Numerator |
Aggregated For: | Proportion and ratio measures |
Definition: | Summation of numerator cases (proportion) or the numerator component (ratio) in a measure's population during the month. The Numerator is the count of all patient-level records with a measure category assignment = ‘E.’ Aggregate all case-level records that are members of a measure's population. Do not eliminate or suppress outliers. Note:
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HBIPS-2 and 3 Strata | Incorrect Overall Calculation | Correct Overall Calculation |
B | 1.3454 | Rounded (1.3454) = 1.345 |
C | 2.0044 | Rounded (2.0044) = 2.004 |
D | 3.2544 | Rounded (3.2544) = 3.254 |
E | 0.0014 | Rounded (0.0014) = 0.001 |
Overall | Sum strata (1.3454 + 2.0044+ 3.2544 + 0.0014) = Round overall (6.6056) = 6.606 | Sum rounded strata (1.345 + 2.004+ 3.254 + 0.001) = overall 6.604 |
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