The Joint Commission
Release Notes (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
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These release notes detail the modifications that have been made to this 2024 version of the Guide for Hospitals (HAP/CAH) released on 3/6/2024. Below are the changes to the 2024 Guide.
Date of Modification | Section | Original Information | Modified Information | Reason |
3/4/2024 | All | Retired HBIPS-5 | n/a | The Joint Commission retired HBIPS-5 as of 12/31/2023 discharges. TOB-2/2a information will remain within the Guide until 2023 data can no longer be resubmitted. |
3/4/2024 | All | Retired TOB-2/2a | n/a | The Joint Commission retired TOB-2/2a as of 12/31/2023 discharges. TOB-2/2a information will remain within the Guide until 2023 data can no longer be resubmitted. |
3/4/2024 | Section 3: Measure Exclusions | PC-05: Exclusive Breast Milk Feeding | PC-05: Exclusive Breast Milk Feeding (through 12/31/2023 Discharges) | Modified the note “(through 12/31/2023 Discharges)” for the existing Measure Exclusions. |
3/4/2024 | Section 3: Measure Exclusions | n/a | PC-05: Exclusive Breast Milk Feeding (starting with 1/1/2024 Discharges)
| Modified the Measure Exclusion Questions and Help Text to match the change that was made to the PC-05 measure starting with 1/1/2024 discharges. For more information, refer to version 2024A of the Specification Manual for Joint Commission National Quality Measures. |
3/4/2024 | Section 3: Measure Exclusions | n/a | SDOH-1: Screening for Social Drivers of Health (starting with calendar year 2024) Exclusions, if any, will be provided later this year. | The Joint Commission will begin using SDOH-1 starting with calendar year 2024. The measure information will be available later this year. Data entry for the year will be available on the same timeframe as Dec 2024 data entry. |
3/4/2024 | Section 3: Measure Exclusions | n/a | SDOH-2: Screen Positive Rate for Social Drivers of Health (starting with calendar year 2024) Exclusions, if any, will be provided later this year. | The Joint Commission will begin using SDOH-1 starting with calendar year 2024. The measure information will be available later this year. Data entry for the year will be available on the same timeframe as Dec 2024 data entry. |
These release notes detail the modifications that have been made to this 2023 version of the Guide for Hospitals (HAP/CAH) released on 7/1/2023. Below are the changes to the 2023 Guide.
Date of Modification | Section | Original Information | Modified Information | Reason |
7/1/2023 | All | Removed HBIPS-1 | When used in an example, replaced HBIPS-1 with HBIPS-5. | The Joint Commission retired HBIPS-1 as of 12/31/2022 discharges. |
7/1/2023
| Section 2: Aggregate Data Dictionary | n/a | Quarterly Sampling Frequency 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. | Added Edits: Added 2 new edits to the data element Hospital Sample Size.
The data entry forms are now evaluating the Quarterly Sampling Frequency and Hospital Sample Size against the Sample Size Requirements for the measure. |
7/1/2023
| Section 2: Aggregate Data Dictionary | Denominator HBIPS-2 and 3: Denominator must be <= Hospital Sample Size * 24 (for HBIPS-2 and 3 Hospital Sample Size is in days, while Denominator must be submitted in hours) | Denominator HBIPS-2 and 3: Denominator must be = Hospital Sample Size * 24 (for HBIPS-2 and 3 Hospital Sample Size is in days, while Denominator must be submitted in hours)
| Modified Edit: Removed the “less than sign” (<) from the data element Denominator edit. For HBIPS-2 and 3 stratum the Denominator must = Hospital Sample Size * 24. Edit is also being corrected on the HBIPS-2 and 3 data entry forms. |
7/1/2023
| Section 2: Aggregate Data Dictionary | n/a
| Number of Unique Patients Within the Numerator If Numerator = zero (0), then Number of Unique Patients Within the Numerator must = zero (0). If Numerator > zero (0), then Number of Unique Patients Within the Numerator must > zero (0). | Added Edits: Added 2 new edits to the data element Number of Unique Patients Within the Numerator. These edits are being added to the data entry forms for Ratio measures (HBIPS-2 and 3). |
7/1/2023 | Section 3: Measure Exclusions | PC-02 Measure Exclusion Question and Help Text: Number of cases excluded for a history of previous live births? Documentation that the patient experienced a live birth prior to the current hospitalization.
| PC-02 Measure Exclusion Question and Help Text: Number of cases excluded for a history of previous births? Documentation that the patient experienced a birth >= 20 weeks gestation regardless of the outcome (i.e. parity > 0) prior to the current hospitalization. | Modified the Measure Exclusion Question and Help Text to match the change that was made to the PC-02 measure starting with 7/1/2023 discharges. For more information, refer to version 2023B of the Specification Manual for Joint Commission National Quality Measures. |
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