Case #

Discharge Disposition

Term Newborn

Admission to NICU

Counted in Measure Exclusion

1

1

1

N

Not counted as a measure exclusion, case will not be assigned a measure category assignment of ‘B’

2

3

1

Y (Documentation that newborn was admitted to NICU)

Number of cases excluded for being admitted to the NICU?

3

2

2 (Documentation that newborn was not term or >= 37 weeks)

Y

Number of cases excluded for not being at term; or with a Gestational Age less than 37 weeks or =UTD?

4

4 (Acute Care Facility)

2

N

Number of cases excluded for being transferred to another hospital?

5

6 (Expired)

2

Y

Number of cases excluded for expiring within the hospital?

ED-1 Median Time from ED Arrival to ED Departure for Admitted ED Patients

How many patients were excluded for

Note: The ED-1 Measure Exclusion data are entered based on the Overall Measure. They are not entered for each stratum.

Question:

Number of cases excluded for not being seen in the ED or unable to determine?

Help Text:

There is no documentation the patient received care in a dedicated emergency department of the facility, OR unable to determine from medical record documentation.

ED-2 Admit Decision Time to ED Departure for Admitted Patients

How many patients were excluded for

Note: The ED-2 Measure Exclusion data are entered based on the Overall Measure. They are not entered for each stratum.

Question:

Number of cases excluded for not being seen in the ED or unable to determine?

Help Text:

There is no documentation the patient received care in a dedicated emergency department of the facility, OR unable to determine from medical record documentation.

HBIPS-2: Hours of physical restraint use

How many patients were excluded for

Question:

No exclusion questions

Help Text:

No help text

HBIPS-3: Hours of seclusion use

How many patients were excluded for

Question:

No exclusion questions

Help Text:

No help text

HBIPS-5: Patients discharged on multiple antipsychotic medications with appropriate justification (retired as of 12/31/2023 discharges)

How many patients were excluded for

Note:  The HBIPS-5 Measure Exclusion data are entered based on the Overall Measure. They are not entered for each stratum.

Question:

Number of cases excluded due to a Length of Stay less than or equal to 3 days?

Help Text:

Length of Stay (in days) = Discharge Date minus (-) Admission Date

Question:

Number of cases excluded because they expired during hospital stay?

Help Text:

The patient expired during the hospital stay.

Question:

Number of cases with a psychiatric diagnosis excluded because they were not patients in an inpatient psychiatric care setting?

Help Text:

Documentation in the medical record that the patient was receiving care primarily for a psychiatric diagnosis but was NOT in an inpatient psychiatric setting, i.e., a psychiatric unit of an acute care hospital or a free-standing psychiatric hospital.

Note: This Measure Exclusion question is required for all hospitals because HBIPS-5 allows patients into the measure if the data element Psychiatric Care Setting is missing. This occurs to support hospitals unable to set the value of this data element before manual data abstraction has occurred.

• Hospitals that can pre-set this data element before the Initial Population is executed will enter a zero.

• Any hospital unable to pre-set this data element will need to answer the Measure Exclusion question based on how they manually abstracted the data for their patients.

Question:

Number of cases excluded due to an unplanned departure resulting in discharge?

Help Text:

Documentation in the medical record of the patient's status at the time the patient left the hospital-based inpatient contains one of the following:

• the patient eloped and was discharged

• the patient failed to return from leave and was discharged

• the patient has not yet been discharged from the hospital

• the patient was transferred/discharged from the inpatient psychiatric unit in an acute care or critical access hospital to another level of care, (i.e., medical unit), at the same acute care or critical access hospital and subsequently discharged from that level of care psychiatric care setting

The intent of this exclusion is to identify and exclude patients with an unplanned departure resulting in discharge. These patients are:

• Patients who discharge or transfer to another level of care in the same hospital are excluded from the measure population since they have not yet been discharged from the hospital.

• Patients who are discharged from the psychiatric setting are included in the measure population.

Question:

Number of cases excluded for being discharged on less than or equal to 1 antipsychotic medications?

Help Text:

The number of routinely scheduled antipsychotic medications prescribed to the patient at discharge as documented in the medical record.

IMM-2: Influenza Immunization

How many patients were excluded for

Note: IMM-2 is a seasonal measure and only reported for the 1^st and 4^th quarters. While organizations may use this measure for cases discharged during the 2^nd or 3^rd quarters, their measure results are not be reported to The Joint Commission. This includes Measure Exclusion data.

Question:

Number of cases excluded due to being less than 6 months of age at admission?

Help Text:

The Patient Age (in months) = Admission Date minus (-) Birthdate

To calculate, use the month and day portion of Admission Date and Birthdate to yield the most accurate age. Only cases with a valid Admission Date and Birthdate should be processed against the measure algorithm.

Question:

Number of cases excluded for having an organ transplant during the current hospitalization?

Help Text:

Patients with an ICD-10-CM Principal or Other Procedure Codes as defined in Appendix A, Table 12.10, Organ Transplant During Current Hospitalization.

Question:

Number of cases excluded for being discharged to an acute care facility?

Help Text:

The patient was discharged (on the day of discharge) to an acute care facility.

Question:

Number of cases excluded for leaving Against Medical Advice (AMA)?

Help Text:

The patient left the facility Against Medical Advice (AMA).

Question:

Number of cases excluded because the patient expired during hospital stay?

Help Text:

The patient expired during the hospital stay.

Question:

Number of cases excluded because a vaccination was indicated, but supply had not been received by the hospital?

Help Text:

Patients for whom vaccination was indicated, but supply had not been received by the hospital due to problems with vaccine production or distribution.

OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients

How many patients were excluded for

Question:

Number of cases excluded for expiring within the hospital?

Help Text:

The patient expired while within the hospital.

Question:

Number of cases excluded for leaving Against Medical Advice (AMA)?

Help Text:

The patient left the facility Against Medical Advice (AMA).

Question:

Number of cases excluded for not being able to determine the Discharge Code?

Help Text:

Discharge Code is not documented or unable to be determined (UTD).

OP-23: Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients Who Received Head CT or MRI Scan Interpretation Within 45 minutes of ED Arrival

How many patients were excluded for

Question:

Number of cases excluded for expiring within the hospital?

Help Text:

The patient expired while within the hospital.

Question:

Number of cases excluded for leaving Against Medical Advice (AMA)?

Help Text:

The patient left the facility Against Medical Advice (AMA).

Question: Number of cases excluded for not being able to determine the Discharge Code?

Help Text:

Discharge Code is not documented or unable to be determined (UTD).

Question:

Number of cases excluded for not having a head CT or MRI scan ordered in the ED?

Help Text:

There is no documentation a head CT or MRI scan was ordered by the physician/APN/PA during the emergency department visit.

Question:

Number of cases excluded for not having the date and time of Last Known Well?

Help Text:

There is no documentation that the date and time of Last Known Well was witnessed or reported, or Unable to Determine from medical record documentation.

Question:

Number of cases excluded for having Last Known Well greater than 120 minutes?

Help Text:

Last Known Well (in minutes) = Outpatient Encounter Date and Arrival Time minus (-) Date Last Known Well and Time Last Known Well.

PC-01: Elective Delivery

How many patients were excluded for

Question:

Number of cases excluded for conditions possibly justifying elective delivery prior to 39 weeks gestation?

Help Text:

Patients with an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.07, Conditions Possibly Justifying Elective Delivery, are to be counted.

Question:

Number of cases excluded for Gestational Age less than 37 or greater than or equal to 39 weeks or equal to UTD?

Help Text:

Gestational Age is the weeks of gestation completed at the time of delivery. This is the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation, irrespective of whether the gestation results in a live birth or a fetal death.

Question:

Number of cases excluded for a history of a prior stillbirth?

Help Text:

Documentation that the patient had a prior history of stillbirth.

PC-02: Cesarean Birth (through 6/30/2023 Discharges)

How many patients were excluded for

Question:

Number of cases excluded for multiple gestations and other presentations?

Help Text:

Patients with an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.09, Multiple Gestations and Other Presentations, are to be counted.

Question:

Number of cases excluded for an outcome of delivery other than a single live birth?

Help Text:

Patients without an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.08, Outcome of Delivery, are to be counted.

Question:

Number of cases excluded for Gestational Age less than 37 weeks or equal to UTD?

Help Text:

Gestational Age is the weeks of gestation completed at the time of delivery. This is the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation, irrespective of whether the gestation results in a live birth or a fetal death.

Question:

Number of cases excluded for a history of previous live births?

Help Text:

Documentation that the patient experienced a live birth prior to the current hospitalization.

PC-02: Cesarean Birth (7/1/2023 through 12/31/2023 Discharges)

How many patients were excluded for

Question:

Number of cases excluded for multiple gestations and other presentations?

Help Text:

Patients with an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.09, Multiple Gestations and Other Presentations, are to be counted.

Question:

Number of cases excluded for an outcome of delivery other than a single live birth?

Help Text:

Patients without an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.08, Outcome of Delivery, are to be counted.

Question:

Number of cases excluded for Gestational Age less than 37 weeks or equal to UTD?

Help Text:

Gestational Age is the weeks of gestation completed at the time of delivery. This is the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation, irrespective of whether the gestation results in a live birth or a fetal death.

Question:

Number of cases excluded for a history of previous births?

Help Text:

Documentation that the patient experienced a birth greater than or equal to 20 weeks gestation regardless of the outcome (i.e. parity greater than 0) prior to the current hospitalization.

PC-02: Cesarean Birth (starting with 1/1/2024 Discharges)

How many patients were excluded for

Question:

Number of cases excluded for multiple gestations and other presentations?

Help Text:

Patients with an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.09, Multiple Gestations, Abnormal Presentations, and Conditions Justifying Cesarean Delivery, are to be counted.

Question:

Number of cases excluded for an outcome of delivery other than a single live birth?

Help Text:

Patients without an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.08, Outcome of Delivery, are to be counted.

Question:

Number of cases excluded for Gestational Age less than 37 weeks or equal to UTD?

Help Text:

Gestational Age is the weeks of gestation completed at the time of delivery. This is the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation, irrespective of whether the gestation results in a live birth or a fetal death.

Question:

Number of cases excluded for a history of previous births?

Help Text:

Documentation that the patient experienced a birth greater than or equal to 20 weeks gestation regardless of the outcome (i.e. parity greater than 0) prior to the current hospitalization.

PC-05: Exclusive Breast Milk Feeding (through 12/31/2023 Discharges)

How many patients were excluded for

Question:

Number of cases excluded due to a Length of Stay greater than 120 days?

Help Text:

Length of Stay (in days) = Discharge Date minus (-) Admission Date

Question:

Number of cases excluded for galactosemia?

Help Text:

Patients with an ICD-10-CM Other Diagnosis Code as defined in Appendix A, Table 11.21, Galactosemia, are to be counted.

Question:

Number of cases excluded for parenteral nutrition?

Help Text:

Patients with an ICD-10-CM Principal or Other Procedure Codes as defined in Appendix A, Table 11.22, Parenteral Nutrition, are to be counted.

Question:

Number of cases excluded for expiring within the hospital?

Help Text:

The patient expired while within the hospital.

Question:

Number of cases excluded for patients being discharged to an acute care facility?

Help Text:

The patient was discharged to an acute care facility.

Question:

Number of cases excluded because patient was discharged to another hospital?

Help Text:

The patient was discharged (on the day of discharge) to another health care facility.

Question:

Number of cases excluded for not being at term; or with a Gestational Age less than 37 weeks or equal to UTD?

Help Text:

There is documentation that the newborn was not at term or less than 37 completed weeks of gestation at the time of birth. Gestational Age is the weeks of gestation completed at the time of delivery. This is the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation, irrespective of whether the gestation results in a live birth or a fetal death.

Question:

Number of cases excluded for being admitted to the NICU?

Help Text:

There is documentation that the newborn was admitted to the Neonatal Intensive Care Unit (NICU) at this hospital at any time during the hospitalization.

PC-05: Exclusive Human Milk Feeding (starting with 1/1/2024 Discharges)

How many patients were excluded for

Question:

Number of cases excluded for galactosemia?

Help Text:

Patients with an ICD-10-CM Other Diagnosis Code as defined in Appendix A, Table 11.21, Galactosemia, are to be counted.

Question:

Number of cases excluded for parenteral nutrition?

Help Text:

Patients with an ICD-10-CM Principal or Other Procedure Codes as defined in Appendix A, Table 11.22, Parenteral Nutrition, are to be counted.

Question:

Number of cases excluded for expiring within the hospital?

Help Text:

The patient expired while within the hospital.

Question:

Number of cases excluded for patients being discharged to an acute care facility?

Help Text:

The patient was discharged to an acute care facility.

Question:

Number of cases excluded because patient was discharged to another hospital?

Help Text:

The patient was discharged (on the day of discharge) to another health care facility.

Question:

Number of cases excluded for not being at term; or with a Gestational Age less than 37 weeks or equal to UTD?

Help Text:

There is documentation that the newborn was not at term or less than 37 completed weeks of gestation at the time of birth. Gestational Age is the weeks of gestation completed at the time of delivery. This is the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation, irrespective of whether the gestation results in a live birth or a fetal death.

Question:

Number of cases excluded for not being able to determine if they were term or their Gestational Age and their Birthweight less than 3000g or equal to UTD?

Help Text:

The documentation for a newborn being at term or less than 37 weeks of gestations at time of birth cannot be determined from medical record documentation, so a UTD is documented. Birthweight is the weight (in grams) of a newborn at the time of delivery. Whether entered in pounds or grams within the hospital's software, all birth weights must be converted to grams prior to measure evaluation.

Question:

Number of cases excluded for being admitted to the NICU?

Help Text:

There is documentation that the newborn was admitted to the Neonatal Intensive Care Unit (NICU) at this hospital at any time during the hospitalization.

PC-06: Unexpected Complications in Term Newborns

How many patients were excluded for

Question:

Number of cases excluded for congenital malformations or genetic diseases; pre-existing fetal conditions; or maternal drug use exposure in-utero?

Help Text:

Patients with an ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A on Table 11.30 (Congenital Malformations), Table 11.31 (Fetal Conditions), or Table 11.32 (Maternal Drug Use) are to be counted. A patient with codes on multiple of these tables is to be counted only once.

Question:

Number of cases excluded for a Birthweight less than 2500g or equal to UTD?

Help Text:

Birthweight is the weight (in grams) of a newborn at the time of delivery. Whether entered in pounds or grams within the hospital's software, all birth weights must be converted to grams prior to measure evaluation.