Name:

Hospital Sample Size

Aggregated For:

All Measures (except SDOH-01, SDOH-2)

Definition:

The count of the number of episodes of care (EOC) records identified for a hospital to perform data abstraction on. This count is after the appropriate sampling methodology, if any, has been applied for the specific time period. This includes both Medicare and Non-Medicare patients in this count.

If the hospital’s Quarterly Sampling Frequency = 'Not Sampling' or the measure is not eligible for sampling, the Hospital Sample Size will = the Initial Population.

Each measure / measure set’s sample size requirements are outlined in the appropriate version of 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. 

Allowable Values:

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

Note: Given only aggregate data is being submitted, the Sample Size should not be defaulted to zero when the hospital has Five or Fewer Discharges for the quarter. The actual Hospital Sample Size and remainder of the data elements must be entered.

Edits:

• If Quarterly Sampling Frequency = "monthly" or "quarterly", then Hospital Sample Size cannot be > Initial Population.

•  If the measure is not eligible for sampling (e.g., HBIPS-2, HBIPS-3), the DDSP will set the Hospital Sample Size = Initial Population and the user will not be able to enter a Hospital Sample Size.

• If the user selected Quarterly Sampling Frequency = 'Not Sampling', the DDSP will require the user to enter the Hospital Sample Size and will validate that it is equal to the Initial Population.

• The Hospital Sample Size for the HBIPS measure topic (set) is derived separately for each stratum. The Overall strata’s Hospital Sample Size = the sum (Hospital Sample Size of the four age strata).

• When Quarterly Sampling Frequency = ‘Monthly’, a Warning Message will be generated if the Hospital Sample Size does not adhere to the monthly sample size requirements for the measure outlined in the appropriate version of the Joint Commission’s Specification Manual for Joint Commission National Quality Measures.

• When Quarterly Sampling Frequency = ‘Quarterly’ or ‘Sampling’, a Warning Message will be generated if the sum of the Hospital Sample Size for the 3 months in the quarter does not adhere to the quarterly sample size requirements for the measure outlined in the appropriate version of 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.

Name:

Initial Population

Aggregated For:

All Measures (except SDOH-01, SDOH-2)

Definition:

This is the count of the number of episodes of care (EOC) records identified for a hospital prior to the application of data integrity filters, measure exclusions, and/or sampling methodology for the specified time period.

This data element is based on the hospital's initial identification of records for a measure set, stratum, or sub-population and includes both Medicare and Non-Medicare patients in this count.

Each measure’s initial patient population requirements are outlined in the appropriate version of the specification manual.

Note:

• HBIPS-2 and 3:  The Initial Population is different for these two measures as it is calculated as the Census Days for the hospital or unit.

Initial Population = (Psychiatric Inpatient Days - Leave Days), submitted as Days

• If the hospital's data has been sampled, this field contains the population from which the sample was originally drawn, NOT the sample size.

• Initial Population must contain the actual number of patients in the population even if the hospital has five or fewer discharges (both Medicare and non-Medicare combined) in a quarter.

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 initial population for the measure for the month. 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. All hospitals are expected to submit data for measure applicable to the services provided and patient populations served.

Edits:

•  The Initial Population for the HBIPS measure topic (set) is derived separately for each age stratum. The Overall (e.g., HBIPS-2a) Initial Population must = the sum of the individual age strata’ Initial Population.

Name:

Measure Exclusion

Aggregated For:

All Measures as documented within Section 3 - Measure Exclusions

Definition:

This data element is a “place-holder” for the denominator exclusion questions asked by the DDSP for each measure. These questions capture the counts of the number of cases excluded from the measure population by receiving a measure category assignment of ‘B’ (Not in Measure Population) when processed through the measure algorithm.

Refer to “Section 3 – Measure Exclusions” within this Guide for the list of denominator exclusion questions that will be asked for each measure.

Allowable Values:

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

Edits:

• Total Exclusion Count (calculated by the DDSP)

• Proportion and Ratio measures:  The sum of Measure Exclusions must be <= the difference between Hospital Sample Size and Denominator.

• Continuous Variable measures:  The sum Measure Exclusions must be <= the difference between Hospital Sample Size and Population.

• Total Count of Cases with Category Y or X (calculated by the DDSP)

• Proportion and Ratio measures:  Hospital Sample Size minus (-) Denominator minus (-) the sum of Measure Exclusions must be >= zero (0)

• Continuous Variable measures:  Hospital Sample Size minus (-) Population minus (-) the sum of Measure Exclusions must be >= zero (0)

Name:

Quarterly Sampling Frequency

Identified For:

All Measures (except SDOH-01, SDOH-2)

Definition:

Indicates if the data being submitted for a hospital has been sampled (either monthly or quarterly) or represents an entire population for the month.

Measures not eligible for sampling (e.g., HBIPS-2, HBIPS-3) will require the Quarterly Sampling Frequency to be set to ‘Sampling Not Allowed’. It is the only selection available for these measures.

A Quarterly Sampling Frequency is required to be selected even if the user is attests to not having any cases in the Initial Population of the measure for a given month.

Quarterly Sampling Frequency must be consistent for the entire quarter for the measure. For stratified measures, this includes all strata for the measure for the quarter.

For example:  If the Quarterly Sampling Frequency for April is monthly, then the Quarterly Sampling Frequency for May and June must be monthly.

Each measure’s sample size requirements are outlined in the appropriate version of the specification manual.

Allowable Values:

This data element is entered via a drop-down box.

The allowable values for all measures except OP-18 and OP-23 are:

• Monthly

• Quarterly

• Not Sampling

The allowable values for OP-18 and OP-23 are (as defined by CMS):

• Sampling

• Not Sampling

Edits:

• Only one Quarterly Sampling Frequency can be selected for the three months of a given calendar quarter.

• If the measure is not eligible for sampling (e.g., HBIPS-2, HBIPS-3), the DDSP will set the Quarterly Sampling Frequency = ‘Sampling not Allowed’.