Versions Compared

Old Version 8

changes.mady.by.user Patty Craig

Saved on

compared with

New Version Current

changes.mady.by.user Patty Craig

Saved on

Key

  • This line was added.
  • This line was removed.
  • Formatting was changed.
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)

...

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:

  • HBIPS-2 and 3:  The Denominator for these measures is not derived from the processing of patient-level data through the measure algorithm. Instead, it is calculated using the Census Days for the hospital or unit.

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.

Edits:

  • If Initial Population = zero, then Denominator may not be entered.

  • Denominator must be <= Hospital Sample Size (for all measures except HBIPS-2 and 3)

  • The Overall strata’s Denominator = the sum (Denominator of the four age strata).

  • HBIPS-2 and 3:  Denominator must be = Hospital Sample Size * 24 (for HBIPS-2 and 3 Hospital Sample Size is in days, while Denominator must be submitted in hours)

...

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:

  • HBIPS-2 and 3: 

    • Strata measures (b, c, d, and e):  The Numerator for these measures is derived from processing patient-level data through the measure algorithm. Use those cases that receive a measure category assignment = ‘E’ to calculate the total number of hours for the events being evaluated by the measure. The Numerator for these measures allows for up to 3 decimal places to account for patients where the event did not occur in full hour increments.

    • Overall measure (a):  The Overall Numerator for these measures are derived from the Numerators calculated for the Strata for the measure. Sum the Strata Numerators that have already been rounded to 3 decimal places. Do not sum the unrounded Strata Numerators and then round the Overall Numerator.

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

...