Finding Your Rate

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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]
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