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Exclusive Breast Milk Feeding

Last updated: September 14, 2018

CMS Measure ID: CMS9v7
Version: 7
NQF Number: 0480
Measure Description:

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

The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk during the entire hospitalization.

Initial Patient Population:

Single newborns with an estimated gestational age at birth of >=37 weeks who are born in the hospital and who did not have a diagnosis of galactosemia, were not subject to parenteral nutrition, and had a length of stay less than or equal to 120 days that ends during the measurement period

Denominator Statement:

Initial Populationinfo-icon

Denominator Exclusions:

Newborns who were admitted to the Neonatal Intensive Care Unit (NICU), who were transferred to an acute care facility, or who expired during the hospitalization

Numerator Statement:

Newborns who were fed breast milk only since birth

Numerator Exclusions:

Not applicable

Denominator Exceptions:

None

Measure Steward: The Joint Commission
Short Name: PC-05
Previous Version:
Improvement Notation:

Improvement noted as an increase in the rate

Guidance:

A discharge to a designated cancer center or children's hospital should be captured as a discharge to an acute care facility.

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

where Reference Date is the date on which you are trying to determine gestational age. For PC-05, Reference Date is the Birth Date.

Note however that the calculation may yield a non-whole number and gestational age should be rounded off to the nearest completed week. 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.

Meaningful Measure: Preventive Care

Specifications

Release Notes

Header

  • Updated Version Number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Added statement to header description that explains measure rate to better align with the clinical intent and the chart-abstracted version of the measure.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Corrected website link for Ip, et al reference.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Corrected website link for the California Department of Public Health reference.

    Measure Section: Reference

    Source of Change: Measure Lead

Logic

  • Removed the 'Single Live Birth' value setinfo-icon from the logic because it was revised and was added to the 'Single Live Born Newborn Born in Hospital' grouping value set.

    Measure Section: Initial Populationinfo-icon

    Source of Change: Measure Lead

  • Added 'code' attribute to all datatypes to conform with QDMinfo-icon 5.3 changes.

    Measure Section: Denominator Exclusionsinfo-icon

    Source of Change: Standards Update

  • Modeled the Location attribute for Encounter, Performed to allow for describing the patient’s presence in more than one location during an individual Encounter to conform with QDM 5.3 changes.

    Measure Section: Denominator Exclusions

    Source of Change: Standards Update

  • Replaced 'Discharge status' attribute with 'Discharge Disposition' attribute for 'Encounter, Performed' and 'Encounter, Active' datatypes to align with QDM 5.3 changes.

    Measure Section: Denominator Exclusions

    Source of Change: Standards Update

  • Added supplemental timing attributes to most datatypes in QDM 5.3 to facilitate accurate retrieval of time related information within CQLinfo-icon logic. Timing attributes now include a time interval, such as prevalence period or relevant period, and/or actual time of documentation with Author Datetime. Relevant period is the general method to describe start and stop times for datatypes. Prevalence period is used for some datatypes to more accurately define onset and abatement times.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Assigned cardinality to each attribute to be more explicit in guiding specificationinfo-icon and implementation of QDM data elements. Cardinality refers to the number of instances of the attribute that can be included in the measure description. Cardinality for most attributes is 0.. 1 (i.e., can occur up to 1 time), but some attributes have a cardinality of 0.. * (i.e., can occur multiple times).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • CQL libraries contain sets of CQL definitions, or CQL expression statements. A context statement, patient or population, can now be used in a CQL library to clearly establish how the subsequent list of CQL expressions will be interpreted. A 'Population' context will interpret the CQL expression with reference to the entire population of the item being counted, patients or encounters. A 'Patient' context will interpret the CQL expression with reference to a single patient. Context statements are not required, but one or more context statements may be used within a library to help clarify how the CQL expressions will be interpreted. Patient context is the default if none is specified.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Replaced measure-defined definitions with similar definitions and functions from CQL shared libraries for consistency across measures.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated measure logic from Quality Data Model (QDM)-based logic to Clinical Quality Language (CQL)-based logic. Information on CQL can be found at the eCQI Resource centerinfo-icon (https://ecqi.healthit.gov/cql). Information about specific versions of the new standards in use for CMS reporting periods can be found at the eCQI Resource Center (https://ecqi.healthit.gov/ecqm-tools-key-resources). Switching from QDM to CQL brings with it many changes, as well as enhanced expression capability, but only those changes with significant impact will be outlined in technical release notes. For example, in the case of timing operators, changes may only be summarized if those changes impact the measure calculation.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Set

The VSACinfo-icon is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set Single Live Born Newborn Born in Hospital (2.16.840.1.113883.3.117.1.7.1.26): Added SNOMEDCT extensional value set (2.16.840.1.113883.3.117.1.7.1.25) including 3 codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 11 SOP codes (299, 32127, 32128, 391, 517, 524, 614, 621, 622, 623, 629) and deleted 3 SOP codes (63, 64, 69).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Deleted 1 SOP code (24).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

External Resources