Date: 09/15/2021 Duration: 1.5 Hours Participants will be able to verbalize changes and updates to Joint Commission Maternal core measures, PC-02 and PC-06 standards, reporting and documentation. on . A hospital's PC-Newborn Population size is 99 cases during the second quarter. Fact Sheet on Maternity Care. Description. Birth weight 3000 grams or more is a proxy to capture term newborns without gestational age recorded in EHR system. /BS 50 0 R RRKd*k2 O! Using the quarterly sampling table for the Mother population, the sample size required 75 cases for the quarter. was introduced in Q4 2018. The Joint Commission reserves the right to change the content of the information as appropriate.. /Rect [80 323.2290039062 136.4620056152 307.7850036621] Learn about the development and implementation of standardized performance measures. For this project, NQF endorsed measures related to elective delivery, episiotomy, and caesarean section rates, as well as prophylactic antibiotic rates for women undergoing cesarean sections. The database collects and evaluates unit-specific nurse-sensitive data from hospitals in the United States." Source: National Database of Nursing Quality Indicators Measures Patient falls /Type /Annot Using the quarterly sampling table for the Exclusive Breast Milk Feeding measure, the sample size required is 109 cases. Participants will be able to verbalize changes and updates to Joint Commission Maternal core measures, PC-02 and PC-06 standards, reporting and documentation. A. The goal of prenatal care is the birth of a healthy child with minimal risk for the mother. outcomes for a newborn. Use of this measure set for quality improvement and public reporting will help strengthen maternal and newborn health and the value of our considerable investment in maternity care.. NPICs expertise and infrastructure can support data QDM v5.5 standards update: Modified 'Encounter, Performed' diagnosis attribute to reference diagnosis codes in value sets specified in the logic. admitted to the Neonatal Intensive Care Unit (NICU) or transferred to a regular intensive care unit (ICU) Although cesarean births can be lifesaving and medically needed, the rapid rise and the extreme hospital variation suggests that "grey-zone" indications seem to be driving much of these trends . A hospital's PC-Newborn Population size is 200 cases for the month of March. A hospital's Mother Population size is 510 cases during March. Value set Birth Weight (2.16.840.1.113762.1.4.1029.194): Added Birth Weight based on change in measure requirements, using birth weight to capture term newborns whose the estimated gestational age at birth information is missing. reflect the reporting period of OctoberMarch. How can patients and families support safety? measures the percentage of women who had an elective cesarean **National Goal Benchmark Source: The United States Department of Health 22 0 obj /ArtBox [0 0 612 792] stated that this measure would only be useful if it's not sampled. NQF# 0471 NTSV Cesarean Birth (now managed by The Joint Commission as PC-02) G/GqY%]#_$~H"8@ii6T%)`oZ# )F7i'g U@14x?%oH&GsvJg3JC While a number of these measures are voluntarily reported as part of endobj The following are Perinatal Care eCQMs used by The Joint Commission. The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk during the entire hospitalization. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. endobj The best practice included using high levels of cholesterol-lowering medications to treat stroke patients. << A hospital's Mother Population size is 400 cases during March. ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 11.01.1 Delivery, a Patient Age (Admission Date Birthdate) >= 8 years and < 65 and a Length of Stay (Discharge Date - Admission Date) 120 days. For PC-05, Reference Date is the Birth Date. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs. hQJ@4mEKHFd-wZkwQ#&p#`ZX94![k@IV, LF7P{(WJH*5#u&){+*ro2*>92Ax'78q/>IF0~*n`JFcx9m/wu"kLW!4IX4uT!+hex|qzp+xjt lr$hSkZ8-4Io |F"X[H 9 (2017). Stakeholder CommentsGeneral and Measure-Specific. The measures address a wide range of care concerns, including childbirth, pregnancy and post-partum care, and newborn care. Importantly, this metric also serves as a balancing measure for other maternal mea-sures such as NTSV (Nulliparous, Term, Singleton, Vertex) cesarean rates and early elective delivery rates. Contact Information Products viamy.ncqa.orgfor analysis that accounts for trend breaks. A discharge to a designated cancer center or children's hospital should be captured as a discharge to an acute care facility. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks. section who have not previously given birth. collection and reporting for collaboratives, insurers, and It is acceptable to calculate Gestational Age using the American College of Obstetricians and Gynecologists ReVITALize guidelines, which define Gestational Age as calculated using the best obstetrical Estimated Due Date (EDD) based on the formula: Gestational Age= (280-(EDD-Reference Date))/7. << expired during the hospitalization Birth weight 3000 grams or more is a proxy to capture term newborns without gestational age recorded in EHR system. endobj /Type /Page subject to parenteral nutrition. /CropBox [0 0 612 792] Strikethrough text highlighted in red indicates information changed from the previous version. << Moved the criteria of length of stay (LOS), diagnosis of galactosemia and subject to parenteral nutrition from initial population to denominator exclusion. In order to identify new antiseizure or disease-modifying therapeutic targets and mechanism-based therapies, we need to (1) understand the mechanisms of initiation, propagation, and termination of seizures at the cellular and network level for different seizure types, including status epilepticus, and in different forms of epilepsy, (2) understand the neural circuits, cell types, cellular . /Tabs /W process and established selection principles. Mothers The population of the PC-Mother measures (PC-01, and 02) are identified using 4 data elements: Admission Date Birthdate Discharge Date Find evidence-based sources on preventing infections in clinical settings. endobj Figures do not account for changes in the underlying measure that could break trending. << >> The This measure is part of a set of five nationally implemented measures by The Joint Commission that address perinatal care (PC-01: Elective Delivery, PC-02: Cesarean Birth, PC-03: Antenatal Steroids, PC-04: Health Care-Associated Bloodstream Infections in Newborns, PC-05: Exclusive Breast Milk Feeding). 225 Chapman Street Suite 200 Providence, RI 02905. By reviewing our patients charts, we can immediately identify what is working and where we can improve. Added text to identify the Quality Data Model (QDM)version used in themeasure specification. /Type /Metadata /N 40 0 R Professor Jean Yang is an applied statistician with expertise in statistical bioinformatics. Text highlighted in green indicates information updated in the new eCQM version. A hospital's Mother Population size is 1500 cases during the second quarter. >> /Metadata 3 0 R /Rect [338.3640136719 337.2290039062 515.7030029297 321.7850036621] |, Prevention and Treatment of Leading Causes of Mortality, Effective Communication and Care Coordination, Maintenance of NQF-Endorsed Performance Measures, 0469: PC-01 Elective Delivery (Joint Commission), 0470: Incidence of Episiotomy (Christiana Care Health System), 0471: PC-02 Cesarean Section (Joint Commission), 0472: Appropriate Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision Cesarean Section (Massachusetts General Hospital/Partners Health Care System), 0473: Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery (Hospital Corporation of America), 0475: Hepatitis B Vaccine Coverage Among All Live Newborn Infants Prior to Hospital or Birthing Facility Discharge (Centers for Disease Control and Prevention), 0476: PC-03 Antenatal Steroids (Joint Commission), 1746: Intrapartum Antibiotic Prophylaxis for Group B Streptococcus (GBS) (Massachusetts General Hospital), 0477: Under 1500g infant Not Delivered at Appropriate Level of Care (California Maternal Quality Care Collaborative), 0478: Neonatal Blood Stream Infection Rate (NQI #3) (Agency for Healthcare Research and Quality), 1731: Health Care-Associated Bloodstream Infections in Newborns (Joint Commission), 0304: Late Sepsis or Meningitis in Very Low Birth Weight (VLBW) Neonates (risk-adjusted) (Vermont Oxford Network), 0480: PC-05 Exclusive Breast Milk Feeding (Joint Commission), 0483: Proportion of Infants 22 to 29 Weeks Gestation Screened for Retinopathy of Prematurity (Vermont Oxford Network). Meta Phillips, R.N.Stroke Compliance Specialist, Sibley Memorial Hospital. >> where Reference Date is the date on which you are trying to determine gestational age. Patients admitted to the hospital for inpatient acute care are included in the PC Newborn Initial population if they have: A Patient Age (Admission Date Birthdate) <= 1 day and ICD-10-CM Principal or Other Diagnosis Codes as defined in Appendix A, Table 11.20.1 Single Liveborn Newborn. Patients and families can use core measure performance to objectively compare hospitals locally or nationally. (2018). /IF 42 0 R >> The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. Since then, the measure has undergone modifications, requiring hospitals to make . reporting by state Medicaid and CHIP agencies. /MediaBox [0 0 612 792] Click on the link(s) below to access measure specific resources: The Joint Commission is a registered trademark of the Joint Commission enterprise. /ZaDb 39 0 R 3 0 obj Read more. In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. These four measures are harmonized with the National Quality Forum (NQF) and Joint Commission perinatal quality measures. The Perinatal and Women's Health Standing Committee oversees NQF's perinatal and women's health measures. Timely postpartum visits provide an opportunity to assess a woman's physical recovery from pregnancy and childbirth. /Type /Annot /H /N The PC measure set is unique in that there are two distinct Initial Patient Populations within the measure set, mothers and newborns. /A 49 0 R /A 51 0 R By . Background . Using the monthly sampling table for the Exclusive Breast Milk Feeding measure, the sample size required is 37 cases. previous years are not available. << This Core Set, which consists of 7 measures from CMS's Child Core Set and 4 measures from the Adult Core Set, will be used by CMS to measure and evaluate progress toward improvement of maternal and perinatal health in Medicaid and CHIP. endstream /Ff 65536 performance on the measure across the larger patient population. Medicaid.gov: the official U.S. government site for Medicare | Medicaid /TrimBox [0 0 612 792] In its 2020 review process, the National Quality Forum endorsed 15 Perinatal and Women's Health measures, of which CMQCC was the developer of three: << National and state averages for Perinatal Care measures focuses on achieving integrated, coordinated, patient-centered care for clinically uncomplicated pregnancies and births. A woman's 'contact' with her antenatal care provider should be more than a simple 'visit' but rather the provision of care and support throughout pregnancy. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. /Helv 38 0 R /AP 14 0 R Data shows that the majority of newborns with gestational age 37 weeks or more have a birth weight 3000 grams or more. Due to exclusions and contraindications, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. 11 0 obj Conducted research in perinatal and ageing brains within a multi-disciplinary team: Designed imaging analysis pipelines to further understanding of connectivity and information processing in the brain, and the mechanisms by which these change due to normal development and disease. HVYk@~?SqKCB gc@QuVG+q;l\cKwWkEPf`VYg(}8|r%,U|y%KRST@yA,L Wu'MA\kt$c&/B >> /Group 34 0 R The study was carried out with the following aims: 1) to assess the quality of perinatal care (PC) by measuring the frequencies of the five PC indicators developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and comparing results with .