Date of Modification

Section

Original Information

Modified Information

Reason

9/19/2024

Section 3: Measure Exclusions

Introduction

Note: Exclusion counts align only with measure algorithm exclusions. The Measure Information Form (MIF) details all exclusions for both the initial patient and measure populations. Initial patient population exclusions are not included in the DDSP.

n/a

Added the Note to the Introduction for Measure Exclusions to assist in better understanding of what to include in the Exclusion counts.

7/22/2024

Section 3: Measure Exclusions

SDOH-1 and SDOH-2

For both measures:

Question: No exclusion questions

Help Text: No help text

Added that there will be no Measure Exclusion questions for these two measures.

6/17/2024

Section 3: Measure Exclusions

PC-05: Exclusive Breast Milk Feeding

PC-05: Exclusive Human Milk Feeding

Modified the name of PC-05 by replacing ‘Breast’ with ‘Human’.

This change starts with 1/1/2024 discharges.

Specification Manual and CAM Data Entry Form had previously been updated. Typo was strictly in this document.

6/17/2024

Section 3: Measure Exclusions

PC-02

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.

PC-02

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.

Modified the Measure Exclusion question’s Help Text for PC-02. Updated the name of Table 11.09 to match the specifications.

This change starts with 1/1/2024 discharges.

Specification Manual and CAM Data Entry Form had previously been updated. Typo was strictly in this document.

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)

• Removed question: Number of cases excluded due to a Length of Stay > 120 days?

• Added question: Number of cases excluded for not being able to determine if they were term or their Gestational Age and their birthweight < 3000g or =UTD?

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

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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.

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.