The Joint Commission
Section 4: Aggregate Data Element Tool (HAP/CAH)
Joint Commission Guide for Data Entry of ChartAbstracted Measures for Hospitals (HAP/CAH)
 Version 2023: Discharges 010123 (1Q2023) through 123123 (4Q2023)
 Version 2024: Discharges 010124 (1Q2024) through 123124 (4Q2024); March 2024
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Included in this section:
Tool #1: applicable to PC01, PC02, PC05, IMM2, VTE6, OP23
Tool #2: applicable to PC06, SUB3, TOB3
Tool #3: applicable to HBIPS2, HBIPS3, HBIPS5
Tool #4: applicable to ED1, ED2
Tool #5: applicable to OP18
Tool #6: applicable to SUB2 and TOB2
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: PC01, PC02, PC05, IMM2, VTE6, OP23
These measures are ratebased proportion measures that are not stratified.
IMM2 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 
Initial Population  User enters data
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  Dropdown box

Hospital Sample Size  User enters data
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

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: PC06, SUB3, TOB3
These measures are ratebased 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.
PC06: The Overall measure is the sum of the Moderate and Severe strata; thus, the Numerator for the Overall Measure will not be entered.
SUB3 and TOB3: 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 
Initial Population  User enters data
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  Dropdown box

Hospital Sample Size  User enters data
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

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 #3
Applicable to the following measures: HBIPS2, HBIPS3, HBIPS5
These measures are ratebased 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.
HBIPS2 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 
Overall (a) Initial Population  User enters data
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  Dropdown box

Overall (a) Hospital Sample Size  User enters data
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

Overall (a) Numerator  User enters data 
Overall (a) Number of Unique Patients within the Numerator  HBIPS2 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
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

Strata B Numerator  User enters data 
Strata B Number of Unique Patients within the Numerator  HBIPS2 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
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

Strata C Numerator  User enters data 
Strata C Number of Unique Patients within the Numerator  HBIPS2 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
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

Strata D Numerator  User enters data 
Strata D Number of Unique Patients within the Numerator  HBIPS2 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
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

Strata E Numerator  User enters data 
Strata E Number of Unique Patients within the Numerator  HBIPS2 and 3 only – user enters data. 
Strata E Observed Rate  Calculated by DDSP 
Measure Exclusion(s)  See Section 3 for specific questions and order for each measure. Note: HBIPS5 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 #4
Applicable to the following measures: ED1, ED2
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 
Initial Population  User enters data
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  Dropdown box

Hospital Sample Size  User enters data
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

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

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

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: ED1 and ED2 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: OP18
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 OP18 measure states that the initial population and sample size are determined using the OPED Throughput criteria and each stratum are derived from this data pull.
The Overall measure is not reported for OP18.
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 
Initial Population  User enters data
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  Dropdown box

Hospital Sample Size  User enters data
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

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

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

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: SUB2 and TOB2
These measures are ratebased proportion measures that are stratified.
TOB2 and SUB2: 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 
Initial Population  User enters data
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  Dropdown box

Hospital Sample Size  User enters data
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 (SUB2 and TOB2)  User enters data

Overall Numerator  User enters data

Overall Observed Rate  Calculated by DDSP

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 (SUB2a and TOB2a)  User enters data

Strata A Numerator  User enters data

Strata A Observed Rate  Calculated by DDSP

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 
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