The Joint Commission
Section 4: Aggregate Data Element Tool (HAP/CAH)
- Kelly C
- Patty Craig
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); as of March 2024
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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, HBIPS-5
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
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
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
|
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: 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
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
|
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: HBIPS-2, HBIPS-3, HBIPS-5
Note: HBIPS-5 was retired as of 12/31/2023 discharges.
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
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
|
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 | 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
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 | 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
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 | 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
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 | 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
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 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) | See Section 3 for specific questions and order for each measure. Note: HBIPS-5 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: 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
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
|
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: 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
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
|
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: 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
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
|
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 (SUB-2 and TOB-2) | 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 (SUB-2a and TOB-2a) | 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 |
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
|
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
|
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 Numerator | User enters data |
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) |
Food Insecurity Observed Rate | Calculated by DDSP (Food Insecurity Numerator / Denominator) |
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