Joint Commission Guide for Data Entry of ChartAbstracted Measures for Hospitals (HAP/CAH)
Version 2023: Discharges 010123 (1Q2023) through 123123 (4Q2023); As of July 1, 2023
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The following aggregate data elements are required to be entered for all measures:
Hospital Sample Size
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 NonMedicare 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. 
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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 subpopulation and includes both Medicare and NonMedicare patients in this count. Each measure’s initial patient population requirements are outlined in the appropriate version of the specification manual. Note:
Initial Population = (Psychiatric Inpatient Days  Leave Days), submitted as Days
 
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.  
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Name:  Measure Exclusion
 
Aggregated For:  All Measures  
Definition:  This data element is a “placeholder” for the denominator exclusion questions asked by the DDSP for each measure. These questions capture the counts of the number of cases excluded from the measure population by receiving a measure category assignment of ‘B’ (Not in Measure Population) when processed through the measure algorithm. Refer to “Section 3 – Measure Exclusions” within this Guide for the list of denominator exclusion questions that will be asked for each measure.  
Allowable Values:  0 through 10,000,000 (whole numbers only)  
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Name:  Quarterly Sampling Frequency
 
Identified For:  All Measures  
Definition:  Indicates if the data being submitted for a hospital has been sampled (either monthly or quarterly) or represents an entire population for the month. Measures not eligible for sampling (e.g., VTE6 and HBIPS2) will require the Quarterly Sampling Frequency to be set to ‘Sampling Not Allowed’. It is the only selection available for these measures. A Quarterly Sampling Frequency is required to be selected even if the user is attests to not having any cases in the Initial Population of the measure for a given month. Quarterly Sampling Frequency must be consistent for the entire quarter for the measure. For stratified measures, this includes all strata for the measure for the quarter. For example: If the Quarterly Sampling Frequency for April is monthly, then the Quarterly Sampling Frequency for May and June must be monthly. Each measure’s sample size requirements are outlined in the appropriate version of the specification manual.  
Allowable Values:  This data element is entered via a dropdown box. The allowable values for all measures except OP18 and OP23 are:
The allowable values for OP18 and OP23 are (as defined by CMS):
 
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