Report

Guide to Finding Your Hospital’s PC-01 EED Rate The Joint Commission PC-01 Measure HRET Encyclopedia of Measures #40 Joint Commission PC 01 Early Elective Deliveries # of Patients delivering newborns Between >=37 and <39 weeks gestation completed MINUS those meeting exclusion criteria: • • • • • • Less than 8 years of age Greater than or equal to 65 years of age Length of stay > 120 days Enrolled in clinical trials Prior uterine surgery ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation as defined in Appendix A, Table 11.07 # of Patients with Elective Deliveries Numerator Note: Numerators are subsets of denominator populations, so criteria applied to denominator also apply to numerator. Defined by: ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes for one or more of the following: • Medical induction of labor as defined in Appendix A, Table 11.05 • Cesarean section as defined in Appendix A, Table 11.06 while not in Labor or experiencing Spontaneous Rupture of Membranes Denominator Joint Commission PC 01 Early Elective Deliveries # of Patients with Elective Deliveries Defined by: ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes for one or more of the following: • Medical induction of labor as defined in Appendix A, Table 11.05 • Cesarean section as defined in Appendix A, Table 11.06 while not in Labor or experiencing Spontaneous Rupture of Membranes Numerator Note: Numerators are subsets of denominator populations, so criteria applied to denominator also apply to numerator. # of Patients delivering newborns Between >=37 and <39 weeks gestation completed Denominator MINUS those meeting exclusion criteria: • • • • • • Less than 8 years of age Greater than or equal to 65 years of age Length of stay > 120 days Enrolled in clinical trials Prior uterine surgery ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation as defined in Appendix A, Table 11.07 Finding Your Rate Step 1 • Count the number of patients that delivered babies between 37 and 38 6/7 weeks gestation. Step 2 • Next, subtract the number of patients that meet criteria listed in Table 11.07 from this number. Then, subtract any patients less than 8 years of age, greater than or equal to 65 years of age, length of stay >120 days, enrolled in clinical trials, or prior uterine surgery. • This is your DENOMINATOR. Step 3 • Now, take your DENOMINATOR from Steps 1 and 2 and subtract the number of non-elective inductions or nonelective scheduled C-sections. • This is your NUMERATOR. Let’s Practice Last month’s delivery log shows that there were 300 babies delivered between 37 and 38 6/7 weeks. Of those 300 deliveries, 200 met criteria listed in Table 11.07, had prior uterine surgery, were in a clinical trial, or met the other listed acceptable medical indications. 300 – 200 = 100 This is your DENOMINATOR Let’s Practice Now that you have found your denominator (100), find your NUMERATOR by counting the number of non-elective deliveries and c-sections (those that come in to the hospital in labor or do not have a scheduled c-section) between 37 and 38 6/7 weeks. For our example, let’s say that number is 98. Subtract that number from your denominator. 100 – 98 = 2. This is your NUMERATOR Let’s Practice Using our example, the PC-01 EED rate for the hospital would be: 2 100 OR 2% Resources https://manual.jointcommission.org/releases/TJC201 3A/MIF0166.html If the link does not automatically open, copy and paste into your browser and search for the PC-01 tab. You will find links to Table 11.07 which lists the ICD-9 codes for medical exclusion criteria for early elective deliveries, other exclusionary criteria, and further explanation of the measure. As always, the HRET HEN data team is here to help as well by sending an e-mail to [email protected]