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Exclusive Breast Milk Feeding

Last updated: May 10, 2019

CMS Measure ID: CMS9v8
Version: 8
NQF Number: 480e
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 Population:

Inpatient hospitalizations for 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:

Inpatient hospitalizations for newborns who were admitted to the Neonatal Intensive Care Unit (NICU), who were transferred to an acute care facility, or other health care facility, or who expired during the hospitalization

Numerator Statement:

Inpatient hospitalizations for 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:
Measure Scoring: Proportion
Measure Type: Process
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: Care is Personalized and Aligned with Patient's Goals

Specifications

Release Notes

Header

  • Updated eCQMinfo-icon version number.

    Measure Section: eCQM Version number

    Source of Change: Annual Update

  • Added 'e' to NQFinfo-icon number.

    Measure Section: NQF Number

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated initial populationinfo-icon statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Updated denominator exclusioninfo-icon statement to include transfers to other health care facility.

    Measure Section: Denominator Exclusionsinfo-icon

    Source of Change: Measure Lead

  • Updated denominator exclusion statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated numeratorinfo-icon statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Removed the ‘Single Live Birth Diagnosis’ datatype to remove redundancy and align with Quality Data Model (QDM)info-icon v5.4 changes.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Added discharge disposition 'Other Health Care Facility' to align with the chart-abstracted measure.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated the names of Clinical Quality Language (CQL)info-icon definitions, functions, and/or aliases for clarification and to align with CQL Style Guideinfo-icon.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Updated TJC_Overall Library version number (TJC_Overall-3.6.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7info-icon Standard: Clinical Quality Language Specificationinfo-icon, Release 1 STUinfo-icon 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MATinfo-icon) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Setinfo-icon

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 Dietary Intake Other than Breast Milk (2.16.840.1.113883.3.117.1.7.1.27): Added 29 SNOMED CT codes.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Breast Milk (2.16.840.1.113883.3.117.1.7.1.30): Added 2 SNOMED CT codes (226790003, 53875002).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Galactosemia (2.16.840.1.113883.3.117.1.7.1.35): Added 5 SNOMED CT codes (124354006, 237963003, 297237003, 297238008, 8849004).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Estimated Gestational Age at Birth (2.16.840.1.113762.1.4.1045.47): Removed Estimated Gestational Age at Birth.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Created Neonatal Intensive Care Unit (NICU) (2.16.840.1.113762.1.4.1029.203) value set with two HSLOC codes (1039-7 and 1040-5).

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Created Neonatal Intensive Care Unit (NICU) (2.16.840.1.113762.1.4.1029.205) grouping value set that includes HSLOC and SNOMED CT extensional value sets (2.16.840.1.113762.1.4.1029.203 and 2.16.840.1.113883.3.117.1.7.1.75).

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Other Health Care Facility (2.16.840.1.113762.1.4.1029.67): Added Other Health Care Facility.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Direct reference code for Gestational age--at birth (LOINC Code (76516-4)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • ​Standardized purpose statement language in value sets across eCQMsinfo-icon. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

External Resources