Version 2023: Discharges 01-01-23 (1Q2023) through 12-31-23 (4Q2023)      

Version 2024: Discharges 01-01-24 (1Q2024) through 12-31-24 (4Q2024); As of March, 2024                                                  

Acknowledgement

Introduction

Using The Joint Commission Guide for Data Entry of Chart-Abstracted Measures

Section 1: Chart-Abstracted Measure Submission

• Direct Data Submission Platform (DDSP)

• How to Use the DDSP

• Chart-Abstraction Measure Selections

• Aggregate Data Entry

• Data Entry Open and Close

• Quality Measure Specifications
  
  

Section 2: Aggregate Data Dictionary

• Introduction

• Data Edits and Statistical Equations

• Stratified Measures

• Attestation Of Zero Cases

• Aggregate Data Elements Overview

• Data Element Dictionary Terms

• Alphabetical List of All Data Elements

  • All Measures

  • Proportion and Ratio Measures

  • Continuous Variable Measures

Section 3: Measure Exclusions

• Introduction

• Measure Algorithm Logic

• Measure Exclusions

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

  • HBIPS-2: Hours of physical restraint use

  • HBIPS-3: Hours of seclusion use

  • HBIPS-5: Patients discharged on multiple antipsychotic medications with appropriate justification

  • IMM-2: Influenza Immunization

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

  • 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

  • PC-01: Elective Delivery

  • PC-02: Cesarean Birth (1/1/2023 through 6/30/2023 Discharges)

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

  • PC-05: Exclusive Breast Milk Feeding

  • PC-06: Unexpected Complications in Term Newborns

  • SDOH-1: Screening for Social Drivers of Health (starting 2024)

  • SDOH-2: Screen Positive Rate for Social Drivers of Health (starting 2024)

  • SUB-2: Alcohol Use Brief Intervention Provided or Offered and SUB-2a: Alcohol Use Brief Intervention

  • SUB-3: Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge

  • TOB-2: Tobacco Use Treatment Provided or Offered and TOB-2a: Tobacco Use Treatment

  • TOB-3: Tobacco Use Treatment Provided or Offered at Discharge

  • VTE-6: Hospital Acquired Potentially-Preventable Venous Thromboembolism

Section 4: Aggregate Data Element Tool

• Introduction

• Measure Exclusion data elements

  • Tool #1

  • Tool #2

  • Tool #3

  • Tool #4

  • Tool #5

  • Tool #6
    
    

Release Notes