The Joint Commission

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Discharge dates beginning 01-01-24 (1Q24) and moving forward until updated

Quarterly Sampling

Within the PC-Newborn population, there are two baby measures Exclusive Human Milk Feeding
(PC-05) and Unexpected Complications in Term Newborns (PC-06). Unexpected Complications in
Term Newborns measure does not allow for sampling. Hospitals selecting cases for the PCNewborn
with Exclusive Human Milk Feeding must ensure that the patient population size for this
measure meets the following conditions.

Quarterly Sample Size Based on PC-Newborn Initial Patient Population to use for Exclusive Human Milk Feeding Average

If Average Quarterly Initial Patient Population Size “N” equals:

≥541 then Minimum Required Sample Size “n” =109

136 - 540 then Minimum Required Sample Size “n” = 20% of Initial Patient Population size

27 - 135 then Minimum Required Sample Size “n” = 27

<27 then no sampling: 100% Initial Patient Population required

Monthly Sampling

Hospitals selecting sample cases for the Mothers must ensure that the Initial Patient Population and sample size for this sampling group meets the following conditions:

Monthly Sample Size Based on Initial Patient Population for Exclusive Human Milk Feeding

Average Monthly Initial Patient Sample Group Size “N” equals:

≥181 then Minimum Required Sampling Group Sample Size “n” =37

46 - 180 then Minimum Required Sampling Group Sample Size “n” = 20% of Initial Patient Population size

9 - 45 then Minimum Required Sampling Group Sample Size “n” = 9

<9 then no sampling: 100% Initial Patient Population required

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