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Continuous Variable Measures (HAP/CAH)

The Joint Commission

Continuous Variable Measures (HAP/CAH)

Joint Commission Guide for Data Entry of Chart-Abstracted Measures for Hospitals (HAP/CAH)
- Version 2023: Discharges 01-01-23 (1Q2023) through 12-31-23 (4Q2023)
- Version 2024: Discharges 01-01-24 (1Q2024) through 12-31-24 (4Q2024); March 2024
- Version 2025: Discharges 01-01-2025 (1Q2025) through 12-31-2025 (4Q2025); January 2025

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Continuous variable measures are measures in which the value of each measurement can fall anywhere along a continuous scale (e.g., the time [in minutes] from hospital arrival to administration of thrombolysis).

The following aggregate data elements are required to be entered for continuous variable measures:

Name:

Maximum Observation

Aggregated For:

Continuous variable measures

Definition:

The measure's largest observed value for those cases represented in the data element Population for the month.

The observed value is the Measurement Value that is calculated for each case as it is processed through the algorithm and received a measure category assignment = ‘D’ for the measure or stratum

Allowable Values:

0 through 10,000,000 .000 (calculate to 4 decimals and round to 3 decimals where 5 rounds up)

Edits:

  • If Population or Initial Population = zero, then Maximum Observation may not be entered.

  • The Maximum Observation for an Overall measure (e.g., ED-1a) must be equal to the highest Maximum Observation of the associated strata measures (e.g., ED-1b and ED-1c).

  • ED-1, ED-2, and OP-18:  The Maximum Observation must be entered as a whole number since the Measurement Value for these measures are calculated as minutes.

  • See additional edits for the Mean Observation data element.

Name:

Mean Observation

Aggregated For:

Continuous variable measures

Definition:

The measure's average observed value for those cases represented in the data element Population for the month.

The observed value is the Measurement Value that is calculated for each case as it is processed through the algorithm and received a measure category assignment = ‘D’ for the measure or strata.

Mean Observation is the measure’s average Measurement Value for the hospital during the month. This is calculated by: (Sum the Measurement Values for all cases within the hospital) divided by the Population count previously derived (count of those cases which receive a measure category assignment = 'D') for the measure or stratum.

The above Mean Observation paragraph displayed as a mathematical formula.

where m = the Population count for the measure or stratum

Allowable Values:

0 through 10,000,000 .000 (calculate to 4 decimals and round to 3 decimals where 5 rounds up)

Edits:

  • If Population or Initial Population = zero, then Mean Observation may not be entered.

  • Minimum Observation must be <= Median Observation and

  • Median Observation must be <= Maximum Observation

 

  • Minimum Observation must be <= Mean Observation and

  • Mean Observation must be <= Maximum Observation

 

Name:

Median Observation

Aggregated For:

Continuous variable measures

Definition:

The measure's midpoint observed value for those cases represented in the data element Population for the month.

The observed value is the Measurement Value that is calculated for each case as it is processed through the algorithm and received a measure category assignment = ‘D’ for the measure or stratum.

To determine the Median, sort the case-level cases by their observed values from the highest value to lowest value: