Exclusive Breast Milk Feeding

Last updated: July 12, 2017

CMS Measure ID: CMS9v3
Version: 3
NQF Number: 0480
Measure Description:

PC-05 Exclusive breast milk feeding during the newborn's entire hospitalization.

PC-05a Exclusive breast milk feeding during the newborn's entire hospitalization considering mother's choice.

Initial Patient Population:

Single term newborns born in the hospital who did not have a diagnosis of galactosemia, were not subject to parenteral infusion, and had a length of stay less than or equal to 120 days.

Denominator Statement:

PC-05 Single term newborns discharged from the hospital.

PC-05a Single term newborns discharged from the hospital.

Denominator Exclusions:

PC-05 Newborns who were admitted to the Neonatal Intensive Care Unit (NICU), who were transferred to another hospital, or who expired during the hospitalization.

PC-05a Newborns who were admitted to the Neonatal Intensive Care Unit (NICU), who were transferred to another hospital, who expired during the hospitalization, or whose mothers chose not to exclusively breast feed.

Numerator Statement:

PC-05 Newborns who were fed breast milk only since birth.

PC-05a Newborns who were fed breast milk only since birth.

Numerator Exclusions:

Not applicable

Denominator Exceptions:

None

Measure Steward: The Joint Commission
Domain: Effective Clinical Care
Short Name: BF
Next Version: Exclusive Breast Milk Feeding
Measure Score: Proportion
Score Type: Process
Improvement Notation:

Increase in the rate

Guidance:

A discharge to a designated cancer center or children’s hospital should be captured as a discharge to another hospital.

The unit of measurement for this measure is an inpatient episode of care. Each distinct hospitalization should be reported, regardless of whether the same patient is admitted for inpatient care more than once during the measurement period. In addition, the eMeasure logic intends to represent events within or surrounding a single occurrence of an inpatient hospitalization.

Specifications

External Resources