Name:

Denominator

Aggregated For:

Proportion and ratio measures

Definition:

Summation of denominator cases (proportion) or the denominator component (ratio) for the measure's population during the month.

The Denominator is the count of each patient-level record with a measure category assignment of ‘D’ or ‘E’ (i.e., [count of ‘D’ + count of ‘E’] = Denominator).

Aggregate all case-level records that are members of a measure's population. Do not eliminate or suppress outliers.

Note:

• HBIPS-2 and 3:  The Denominator for these measures is not derived from the processing of patient-level data through the measure algorithm. Instead, it is calculated using the Census Days for the hospital or unit.

Denominator = (Psychiatric Inpatient Days - Leave Days), submitted as Hours

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 denominator (i.e., ‘zero denominator’) for the measure for the month. Hospitals with denominator cases are expected to enter the appropriate value for each measure or strata.

Edits:

• If Initial Population = zero, then Denominator may not be entered.

• Denominator must be <= Hospital Sample Size (for all measures except HBIPS-2 and 3)

• The Overall strata’s Denominator = the sum (Denominator of the four age strata).

• HBIPS-2 and 3:  Denominator must be = Hospital Sample Size * 24 (for HBIPS-2 and 3 Hospital Sample Size is in days, while Denominator must be submitted in hours)

Name:

Number of Unique Patients Within the Numerator

Aggregated For:

Ratio measures only

Definition:

For the HBIPS-2 and 3, this is the number of unique patients represented in the data element Numerator. If no event occurred during the month (Numerator = 0), enter a zero (0) for this data element.

Examples for a single patient with multiple numerator events:

• on the same day (e.g., August 12^th) is counted as 1 unique patient for August.

• on different days in the same month (e.g., August 12^th and 15^th) is counted as 1 unique patient for August.

• in different months (e.g., August 12^th and September 15^th) is counted as 1 unique patient for August and 1 unique patient for September.

Allowable Values:

0 through 10,000,000 (whole numbers only)

Edits:

• If Denominator or Initial Population = zero, then Number of Unique Patients Within the Numerator may not be entered.

• If Numerator = zero (0), then Number of Unique Patients Within the Numerator must = zero (0).

• If Numerator > zero (0), then Number of Unique Patients Within the Numerator must > zero (0).

• HBIPS-2 and 3: The Overall strata’s Number of Unique Patients Within the Numerator = the sum (Number of Unique Patients Within the Numerator of the four age strata).

• HBIPS-2 and 3: Number of Unique Patients within the Numerator must be <= Hospital Sample Size

Name:

Numerator

Aggregated For:

Proportion and ratio measures

Definition:

Summation of numerator cases (proportion) or the numerator component (ratio) in a measure's population during the month.

The Numerator is the count of all patient-level records with a measure category assignment = ‘E.’

Aggregate all case-level records that are members of a measure's population. Do not eliminate or suppress outliers.

Note:

• HBIPS-2 and 3: 

  • Strata measures (b, c, d, and e):  The Numerator for these measures is derived from processing patient-level data through the measure algorithm. Use those cases that receive a measure category assignment = ‘E’ to calculate the total number of hours for the events being evaluated by the measure. The Numerator for these measures allows for up to 3 decimal places to account for patients where the event did not occur in full hour increments.

  • Overall measure (a):  The Overall Numerator for these measures are derived from the Numerators calculated for the Strata for the measure. Sum the Strata Numerators that have already been rounded to 3 decimal places. Do not sum the unrounded Strata Numerators and then round the Overall Numerator.

HBIPS-2 and 3 Strata

Incorrect Overall Calculation

Correct Overall Calculation

B

1.3454

Rounded (1.3454) = 1.345

C

2.0044

Rounded (2.0044) = 2.004

D

3.2544

Rounded (3.2544) = 3.254

E

0.0014

Rounded (0.0014) = 0.001

Overall

Sum strata (1.3454 + 2.0044+ 3.2544 + 0.0014) =

Round overall (6.6056) = 6.606

Sum rounded strata (1.345 + 2.004+ 3.254 + 0.001) =

overall 6.604

Allowable Values:

• 0 through 10,000,000 (for proportion measures, whole numbers only)

• HBIPS-2 and 3 strata: 0 through 10,000,000.000 (calculate to 4 decimals and round to 3 decimals where 5 rounds up)

• HBIPS-2 and 3 overall: 0 through 10,000,000.000 (do not round, instead sum the rounded strata Numerators)

Edits:

• If Denominator or Initial Population = zero, then Numerator may not be entered.

• Non-stratified measures:

  • Numerator must be <= Denominator

•  Stratified measures where only one Denominator is entered:

  • each stratum’s Numerator must be <= the Denominator

  • the sum of each stratum’s Numerator must be <= the Denominator

•  Stratified measures where a Denominator is entered for each stratum:

  • each stratum’s Numerator must be <= that stratum’s Denominator

  • HBIPS topic:  The Overall strata’s Numerator = the sum (Denominator of the four age strata).