View Source

Joint Commission Guide for Data Entry of Chart-Abstracted Measures for Hospitals (HAP/CAH)
- Version 2023: Discharges 01-01-2023 (1Q2023) through 12-31-2023 (4Q2023)

- Version 2024: Discharges 01-01-2024 (1Q2024) through 12-31-2024 (4Q2024); March 2024

- Version 2025: Discharges 01-01-2025 (1Q2025) through 12-31-2025 (4Q2025); January 2025

Included in this section:

Tool #1: applicable to PC-01, PC-02, PC-05, IMM-2, VTE-6, OP-23
Tool #2: applicable to PC-06, SUB-3, TOB-3
Tool #3: applicable to HBIPS-2, HBIPS-3
Tool #4: applicable to ED-1, ED-2
Tool #5: applicable to OP-18
Tool #6: applicable to SUB-2 and TOB-2
Tool #7: applicable to SDOH-1
Tool #8: applicable to SDOH-2

Introduction

This section of the manual provides several tools to assist hospitals and their vendors in understanding the order in which the aggregate data elements will be entered into the Direct Data Submission Platform (DDSP).

Measure Exclusion data elements

Each Measure Exclusion question is entered once for the measure. This is true even if the measure is stratified.

These Tools depict the order of where the Measure Exclusion elements are entered versus the Statistical data elements. However, the specific questions and their exact order for each measure is provided in Section 3.

Tool #1

Applicable to the following measures: PC-01, PC-02, PC-05, IMM-2, VTE-6, OP-23

Note: VTE-6 was retired as of 12/31/2024 discharges.

These measures are rate-based proportion measures that are not stratified.
IMM-2 is seasonal, so the DDSP will only allow entry of data for 1Q and 4Q each year. The other two quarters will not be accessible.

Aggregate Data Element	Data Entry Information
Initial Population	User enters data Zero Initial Population Attestation for the month will be prompted at this point in data entry. 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.
Quarterly Sampling Frequency	Drop-down box If the measure does not allow sampling, the drop-down box will not be available.
Hospital Sample Size	User enters data If the measure does not allow sampling or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user cannot update.
Denominator	User enters data Zero Denominator Attestation for the month will be prompted at this point in data entry.
Numerator	User enters data
Observed Rate	Calculated by DDSP
Measure Exclusion(s)	See Section 3 for specific questions and order for each measure
Total Exclusion Count	Calculated by DDSP
Total Count of Cases with Category Y or X	Calculated by DDSP

Tool #2

Applicable to the following measures: PC-06, SUB-3, TOB-3

These measures are rate-based proportion measures that are stratified.
The specifications for these measures state that the initial population and sample size are determined for the Overall measure and each stratum are derived from this data pull.
These measures require the entry of multiple Numerator values.
- PC-06: The Overall measure is the sum of the Moderate and Severe strata; thus, the Numerator for the Overall Measure will not be entered.
- SUB-3 and TOB-3: The Overall measures are not the sum of the measure’s strata; therefore, both the Overall and strata Numerators must be entered.

Aggregate Data Element	Data Entry Information
Initial Population	User enters data Zero Initial Population Attestation for the month will be prompted at this point in data entry. 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.
Quarterly Sampling Frequency	Drop-down box If the measure does not allow sampling, the drop-down box will not be available.
Hospital Sample Size	User enters data If the measure does not allow sampling or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user will not be able to update.
Denominator	User enters data Zero Denominator Attestation will be prompted at this point in data entry.
Numerator	User enters data Multiple Numerators are entered based on each measure’s specifications.
Observed Rate	Calculated by DDSP Multiple Observed Rates are calculated, one for the Overall measure and one for each stratum
Measure Exclusion(s)	See Section 3 for specific questions and order for each measure
Total Exclusion Count	Calculated by DDSP
Total Count of Cases with Category Y or X	Calculated by DDSP

Tool #3

Applicable to the following measures: HBIPS-2, HBIPS-3

These measures are rate-based proportion and ratio measures that are stratified.
These measures require all data elements to be entered for the Overall measure and each of the four strata measures.
- The HIBPS measure topic specifications state that the initial population and sample size are determined for each stratum.
- HBIPS-2 and 3 require the additional data element “Number of Unique Patients within the Numerator” that must be entered. It is depicted below in the order it will be entered for these measures.

Aggregate Data Element	Data Entry Information
Overall (a) Initial Population	User enters data Zero Initial Population Attestation for the month will be prompted at this point in data entry. 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.
Overall (a) Quarterly Sampling Frequency	Drop-down box If the measure does not allow sampling, the drop-down box will not be available.
Overall (a) Hospital Sample Size	User enters data If the measure does not allow sampling or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user cannot update.
Overall (a) Denominator	User enters data Zero Denominator Attestation will be prompted at this point in data entry.
Overall (a) Numerator	User enters data
Overall (a) Number of Unique Patients within the Numerator	HBIPS-2 and 3 only – user enters data.
Overall (a) Observed Rate	Calculated by DDSP
Strata B Initial Population	User enters data
Strata B Hospital Sample Size	User enters data If the measure does not allow sampling or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user cannot update.
Strata B Denominator	User enters data Zero Denominator Attestation will be prompted at this point in data entry.
Strata B Numerator	User enters data
Strata B Number of Unique Patients within the Numerator	HBIPS-2 and 3 only – user enters data.
Strata B Observed Rate	Calculated by DDSP
Strata C Initial Population	User enters data
Strata C Hospital Sample Size	User enters data If the measure does not allow sampling or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user cannot update.
Strata C Denominator	User enters data Zero Denominator Attestation will be prompted at this point in data entry.
Strata C Numerator	User enters data
Strata C Number of Unique Patients within the Numerator	HBIPS-2 and 3 only – user enters data.
Strata C Observed Rate	Calculated by DDSP
Strata D Initial Population	User enters data
Strata D Hospital Sample Size	User enters data If the measure does not allow sampling or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user cannot update.
Strata D Denominator	User enters data Zero Denominator Attestation will be prompted at this point in data entry.
Strata D Numerator	User enters data
Strata D Number of Unique Patients within the Numerator	HBIPS-2 and 3 only – user enters data.
Strata D Observed Rate	Calculated by DDSP
Strata E Initial Population	User enters data
Strata E Hospital Sample Size	User enters data If the measure does not allow sampling or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user cannot update.
Strata E Denominator	User enters data Zero Denominator Attestation will be prompted at this point in data entry.
Strata E Number of Unique Patients within the Numerator	HBIPS-2 and 3 only – user enters data.
Strata E Observed Rate	Calculated by DDSP
Measure Exclusion(s)	HBIPS-2 and 3 do not have Measure Exclusions.
Total Exclusion Count	Since there are no Measure Exclusion questions, a Total Exclusion Count cannot be calculated by the DDSP.
Total Count of Cases with Category Y or X	The Total Count of Cases with Category Y or X cannot be calculated by the DDSP due to the difference in data definitions.

Tool #4

Applicable to the following measures: ED-1, ED-2

These measures are continuous variable measures that are stratified and for which the Overall measure is reported.
These measures require the entry of the Initial Population, Quarterly Sampling Frequency, and Hospital Sample Size once.
- The specifications for the ED measures state that the initial population and sample size are determined using the Global criteria. The Overall measures and each stratum are derived from this data pull.
These measures require all data elements to be entered for the Overall measure and each of the two strata measures.

Aggregate Data Element	Data Entry Information
Initial Population	User enters data Zero Initial Population Attestation for the month will be prompted at this point in data entry. 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.
Quarterly Sampling Frequency	Drop-down box If the measure does not allow sampling, the drop-down box will not be available.
Hospital Sample Size	User enters data If the measure does not allow sampling or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user cannot update.
Overall (a) Population	User enters data Zero Population Attestation will be prompted at this point in data entry.
Overall (a) Minimum Observation	User enters data
Overall (a) Median Observation	User enters data
Overall (a) Maximum Observation	User enters data
Overall (a) Mean Observation	User enters data
Overall (a) Standard Deviation of the Observation	User enters data
Strata B Population	User enters data Zero Population Attestation will be prompted at this point in data entry.
Strata B Minimum Observation	User enters data
Strata B Median Observation	User enters data
Strata B Maximum Observation	User enters data
Strata B Mean Observation	User enters data
Strata B Standard Deviation of the Observation	User enters data
Strata C Population	User enters data Zero Population Attestation will be prompted at this point in data entry.
Strata C Minimum Observation	User enters data
Strata C Median Observation	User enters data
Strata C Maximum Observation	User enters data
Strata C Mean Observation	User enters data
Strata C Standard Deviation of the Observation	User enters data
Measure Exclusion(s)	See Section 3 for specific questions and order for each measure. Note: ED-1 and ED-2 Measure Exclusions are entered based on the Overall Measure. They are not entered for each stratum.
Total Exclusion Count	Calculated by DDSP
Total Count of Cases with Category Y or X	Calculated by DDSP

Tool #5

Tool #5 is applicable to the following measures: OP-18

These measures are continuous variable measures that are stratified and for which the Overall measure is not reported.
These measures require the entry of the Initial Population, Quarterly Sampling Frequency, and Hospital Sample Size once.
- The specifications for the OP-18 measure states that the initial population and sample size are determined using the OP-ED Throughput criteria and each stratum are derived from this data pull.
  - The Overall measure is not reported for OP-18.
These measures require all data elements to be entered for each of the measure’s strata. Data is not entered for the Overall measure.

Aggregate Data Element	Data Entry Information
Initial Population	User enters data Zero Initial Population Attestation for the month will be prompted at this point in data entry. 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.
Quarterly Sampling Frequency	Drop-down box If the measure does not allow sampling, the drop-down box will not be available.
Hospital Sample Size	User enters data If the measure does not allow sampling or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user cannot update.
Strata B Population	User enters data Zero Population Attestation will be prompted at this point in data entry.
Strata B Minimum Observation	User enters data
Strata B Median Observation	User enters data
Strata B Maximum Observation	User enters data
Strata B Mean Observation	User enters data
Strata B Standard Deviation of the Observation	User enters data
Strata C Population	User enters data Zero Population Attestation will be prompted at this point in data entry.
Strata C Minimum Observation	User enters data
Strata C Median Observation	User enters data
Strata C Maximum Observation	User enters data
Strata C Mean Observation	User enters data
Strata C Standard Deviation of the Observation	User enters data
Strata D Population	User enters data Zero Population Attestation will be prompted at this point in data entry.
Strata D Minimum Observation	User enters data
Strata D Median Observation	User enters data
Strata D Maximum Observation	User enters data
Strata D Mean Observation	User enters data
Strata D Standard Deviation of the Observation	User enters data
Measure Exclusion(s)	See Section 3 for specific questions and order for each measure
Total Exclusion Count	Calculated by DDSP
Total Count of Cases with Category Y or X	Calculated by DDSP

Tool #6

Tool #6 is applicable to the following measures: SUB-2 and TOB-2

Note: TOB-2/2a was retired as of 12/31/2023 discharges.

These measures are rate-based proportion measures that are stratified.
TOB-2 and SUB-2: The Overall measures and the associated strata have different Denominators.
These measures require the entry of separate data for the Overall and associated strata measures. This includes the Measure Exclusion questions.

Aggregate Data Element	Data Entry Information
Initial Population	User enters data Zero Initial Population Attestation for the month will be prompted at this point in data entry. 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.
Quarterly Sampling Frequency	Drop-down box If the measure does not allow sampling, the drop-down box will not be available.
Hospital Sample Size	User enters data If the measure does not allow sampling or the hospital did not sample, Hospital Sample Size will be set equal to the Initial Population and the user will not be able to update.
Overall Denominator (SUB-2 and TOB-2)	User enters data Zero Denominator Attestation will be prompted at this point in data entry.
Overall Numerator	User enters data Multiple Numerators are entered based on each measure’s specifications.
Overall Observed Rate	Calculated by DDSP Multiple Observed Rates are calculated, one for the Overall measure and one for each stratum
Overall Measure Exclusion(s)	See Section 3 for specific questions and order for each measure
Overall Total Exclusion Count	Calculated by DDSP
Overall Total Count of Cases with Category Y or X	Calculated by DDSP
Strata A Denominator (SUB-2a and TOB-2a)	User enters data Zero Denominator Attestation will be prompted at this point in data entry.
Strata A Numerator	User enters data Multiple Numerators are entered based on each measure’s specifications.
Strata A Observed Rate	Calculated by DDSP Multiple Observed Rates are calculated, one for the Overall measure and one for each stratum
Strata A Measure Exclusion(s)	See Section 3 for specific questions and order for each measure. Note: Measure Exclusions which are the same between the Overall Measure and the Strata a defaulted by the DDSP. Only those Measure Exclusions which are unique for the Strata must be entered.
Strata A Total Exclusion Count	Calculated by DDSP
Strata A Total Count of Cases with Category Y or X	Calculated by DDSP

Tool #7

Applicable to the following measures: SDOH-1

Note: SDOH-1 became available as of 2024 discharges.

This measure is a rate-based proportion measure that is not stratified.
This measure is an Annual measure, meaning a single data point will be entered.

Aggregate Data Element	Data Entry Information
Denominator	User enters data Zero Denominator Attestation for the month will be prompted at this point in data entry.
Numerator	User enters data
Observed Rate	Calculated by DDSP

Tool #8

Applicable to the following measures: SDOH-2

Note: SDOH-2 became available as of 2024 discharges.

This measure is a rate-based proportion measure that is stratified.
This measure is an Annual measure, meaning a single data point will be entered.
SDOH-2 requires entry of separate numerator for:
- SDOH-2 Food
- SDOH-2 Housing
- SDOH-2 Transportation
- SDOH-2 Utility
- SDOH-2 Interpersonal

Aggregate Data Element	Data Entry Information
Denominator	User enters data Zero Denominator Attestation will be prompted at this point in data entry.
Food Insecurity Numerator	User enters data
Housing Instability Numerator	User enters data
Transportation Needs Numerator	User enters data
Utility Difficulties Numerator	User enters data
Interpersonal Safety Numerator	User enters data
Food Insecurity Observed Rate	Calculated by DDSP (Food Insecurity Numerator / Denominator)
Housing Instability Observed Rate	Calculated by DDSP (Housing Instability Numerator / Denominator)
Transportation Needs Observed Rate	Calculated by DDSP (Transportation Needs Numerator / Denominator)
Utility Difficulties Observed Rate	Calculated by DDSP (Utility Difficulties Numerator / Denominator)
Interpersonal Safety Observed Rate	Calculated by DDSP (Interpersonal Safety Numerator / Denominator)

Continue to the next section: Release Notes

Return to the Table of Contents

Joint Commission Guide for Data Entry of Chart-Abstracted Measures for Hospitals (HAP/CAH)- Version 2023: Discharges 01-01-2023 (1Q2023) through 12-31-2023 (4Q2023)