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)

- Version 2024: Discharges 01-01-24 (1Q2024) through 12-31-24 (4Q2024); March 2024

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Introduction

This section of the manual describes the aggregate data elements hospitals must calculate prior to entering their chart-abstracted measure data into the Direct Data Submission Platform (DDSP). It includes the definition and allowable values for each aggregate data element. In addition, data edits and statistical equations are provided as appropriate.

Data Edits and Statistical Equations

For each aggregate data element, data edits and statistical equations are provided below as appropriate. The statistical equations have been provided to assist in your proper calculation of these data element. The edits will be executed on the DDSP and will result in an error message. In addition, the DDSP will ensure data is entered correctly from the perspective of allowable values and whole numbers.

Stratified Measures

Stratified measures are classified into several groups (strata) to assist in the analysis and interpretation of the measure. The overall or un-stratified measure evaluates all the strata together. The stratified measure or each stratum consists of a subset of the overall measure.

Measures which are stratified require the appropriate aggregate data to be entered for each stratum associated to the measure. For example:

• PC-06 contains three strata (Overall, Severe, and Moderate).

  • The Denominator value for all three strata is the same, so it is only entered once.

  • The Severe Rate and Moderate Rate strata have different Numerator values, so a value for each of these strata must be entered.

•  HBIPS-5 contains five strata (Overall, Children, Adolescent, Adult, and Older Adult).

  • The Denominator and Numerator values for each of the five strata are different, so a separate value for both Denominator and Numerator must be entered for each stratum.

  • NOTE: HBIPS-5 was retired as of 12/31/2023 discharges.

• ED-1 contains three strata (Overall, Reporting, and Psychiatric/Mental Health Patients).

  • The Maximum Observation, Mean Observation, Median Observation, Minimum Observation, Population, and Standard Deviation of the Observation must be entered for each stratum.

Attestation Of Zero Cases

Hospitals will be capable of attesting to having zero cases in two different manners.

Initial Population:  If a zero is entered in the Initial Population field for a month, the user will be prompted to check the Zero Initial Population Attestation box to attest that the zero Initial Population count is valid. This attestation 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.

Denominator:  If a zero is entered into the Denominator field for a month, the user will be promoted to check the Zero Denominator Attestation box to attest that the zero Denominator count is valid.

Aggregate Data Elements Overview

The aggregate data elements that require entry on the DDSP are divided below into (1) those required for all measures, (2) those required for proportion or ratio measures, and (3) those required for continuous variable measures.

The DDSP calculates the following data elements based upon the aggregate data entered for each measure, or strata and reporting time period.

Many of the aggregate data elements utilize the measure category assignment, which is calculated for each case as it is processed through a measure or stratum’s algorithm. One measure category assignment is expected for each case, for every measure or stratum, that a hospital is reporting. Refer to the data element Measure Category Assignment in 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. 

Observed Rate:

Observed rates are used to measure hospital performance and is calculated for proportion and ratio measures. It is based on the aggregated data entered for the hospital.

The Observed Rate is calculated as the number of Numerator cases divided by the number of Denominator cases (Numerator / Denominator). The Observed Rate is calculated to 4 decimals and round to 3 decimals where 5 rounds up. For stratified measures, an Observed Rate is calculated for each stratum.

Some measures calculate the Observed Rate “as a rate per 1,000” (e.g., PC-06) or “as a ratio” where the denominator basis is per 1,000 (e.g., HBIPS-2 and 3). For these measures, the Observed Rate is calculated as the [(number of Numerator cases divided by the number of Denominator cases) times 1,000] or (Numerator / Denominator) * 1,000).

Total Count of Cases with Category Y or X: 

Cases which are not accounted for by the entered Measure Exclusion data will be assumed to have received a measure category assignment of ‘Y’ (UTD Allowable Value Does Not Allow Calculation of the Measure) or ‘X’ (Data Are Missing) and will be counted as such by the DDSP.

Total Exclusion Count: 

Count of cases which are accounted for by the entered Measure Exclusion data. Measure exclusions are those cases which received a measure category assignment of ‘B’ when processed through the measure algorithm.

Continue to the next section: Data Element Dictionary Terms

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