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Date of Modification | Section | Original Information | Modified Information | Reason |
12/31/2024 | Section 2: Aggregate Data Dictionary: All Measures Data Elements: Hospital Sample Size Initial Population Quarterly Sampling Frequencies | Aggregated For: All Measures | Aggregated For: All Measures (except SDOH-01, SDOH-2) | These three data elements are not collected for SDOH-1 and SDOH-2. |
12/31/2024 | Section 2: Aggregate Data Dictionary: All Measures Data Element: Measure Exclusion | Aggregated For: All Measures | Aggregated For: All Measures as documented within Section 3 - Measure Exclusions | This data element is not used for SDOH-1, SDOH-2, HBIPS-2, and HBIPS-3. Further clarified that the usage of the data element is specified in Section 3 - Measure Exclusions. |
12/31/2024 | Section 2: Aggregate Data Dictionary: Proportion and Ratio Measures Data Element: Denominator | n/an/a |
| Added notes within the Edit section related to the fact that SDOH-1 and SDOH-2 do not capture Hospital Sample Size and Initial Population and, therefore, there are no edits against those data elements. |
12/31/2024 | Section 4: Aggregate Data Element Tool | N/A | Added Tool #7 for SDOH-1 Added Tool #8 for SDOH-2 | Initial data collection for SDOH-1 and SDOH-2 starts with 2024. These are both Annual measures. |
9/19/2024 | Section 3: Measure Exclusions | Introduction Note: Exclusion counts align only with measure algorithm exclusions. The Measure Information Form (MIF) details all exclusions for both the initial patient and measure populations. Initial patient population exclusions are not included in the DDSP. | n/a | Added the Note to the Introduction for Measure Exclusions to assist in better understanding of what to include in the Exclusion counts. |
7/22/2024 | Section 3: Measure Exclusions | SDOH-1 and SDOH-2 | For both measures: Question: No exclusion questions Help Text: No help text | Added that there will be no Measure Exclusion questions for these two measures. |
6/17/2024 | Section 3: Measure Exclusions | PC-05: Exclusive Breast Milk Feeding | PC-05: Exclusive Human Milk Feeding | Modified the name of PC-05 by replacing ‘Breast’ with ‘Human’. This change starts with 1/1/2024 discharges. Specification Manual and CAM Data Entry Form had previously been updated. Typo was strictly in this document. |
6/17/2024 | Section 3: Measure Exclusions | PC-02 Question: Number of cases excluded for multiple gestations and other presentations? Help Text: Patients with an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.09, Multiple Gestations and Other Presentations, are to be counted. | PC-02 Question: Number of cases excluded for multiple gestations and other presentations? Help Text: Patients with an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.09, Multiple Gestations, Abnormal Presentations, and Conditions Justifying Cesarean Delivery, are to be counted. | Modified the Measure Exclusion question’s Help Text for PC-02. Updated the name of Table 11.09 to match the specifications. This change starts with 1/1/2024 discharges. Specification Manual and CAM Data Entry Form had previously been updated. Typo was strictly in this document. |
3/4/2024 | All | Retired HBIPS-5 | n/a | The Joint Commission retired HBIPS-5 as of 12/31/2023 discharges. TOB-2/2a information will remain within the Guide until 2023 data can no longer be resubmitted. |
3/4/2024 | All | Retired TOB-2/2a | n/a | The Joint Commission retired TOB-2/2a as of 12/31/2023 discharges. TOB-2/2a information will remain within the Guide until 2023 data can no longer be resubmitted. |
3/4/2024 | Section 3: Measure Exclusions | PC-05: Exclusive Breast Milk Feeding | PC-05: Exclusive Breast Milk Feeding (through 12/31/2023 Discharges) | Modified the note “(through 12/31/2023 Discharges)” for the existing Measure Exclusions. |
3/4/2024 | Section 3: Measure Exclusions | n/a | PC-05: Exclusive Breast Milk Feeding (starting with 1/1/2024 Discharges)
| Modified the Measure Exclusion Questions and Help Text to match the change that was made to the PC-05 measure starting with 1/1/2024 discharges. For more information, refer to version 2024A of the Specification Manual for Joint Commission National Quality Measures. |
3/4/2024 | Section 3: Measure Exclusions | n/a | SDOH-1: Screening for Social Drivers of Health (starting with calendar year 2024) Exclusions, if any, will be provided later this year. | The Joint Commission will begin using SDOH-1 starting with calendar year 2024. The measure information will be available later this year. Data entry for the year will be available on the same timeframe as Dec 2024 data entry. |
3/4/2024 | Section 3: Measure Exclusions | n/a | SDOH-2: Screen Positive Rate for Social Drivers of Health (starting with calendar year 2024) Exclusions, if any, will be provided later this year. | The Joint Commission will begin using SDOH-1 starting with calendar year 2024. The measure information will be available later this year. Data entry for the year will be available on the same timeframe as Dec 2024 data entry. |
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