Frequently Asked Data Submission Questions

Choose a topic from the list below to view frequently asked questions. If you have other data-related questions that are not covered here, please contact Dolores Hagan via e-mail at dhagan@kyha.com.

 

Early Elective Delivery (EED)

Q: Does the denominator for the EED Measure # 40—Elective Deliveries at ≥37 and <39 weeks gestation (JC PC-01) include only elective deliveries or all deliveries at ≥37 and <39 weeks gestation.

A: In review of The Joint Commission specification manual and algorithm for this measure, the denominator is determined as follows: All deliveries at ≥37 and <39 weeks gestation completed

Except:

  1. Patients with documented justification for EED as defined in Appendix A, Table 11.07
  2. Patient is enrolled in a clinical trial
  3. Patients with prior classical cesarean section or myomectomy

 

Preventable Readmissions:

Q: I do not have 2011 readmission data and chose to use January through June 2012 as my baseline. The Comprehensive Data System will not allow me to enter a 2012 date in the Baseline data fields. Where do I enter my January through June 2012 data?

A: Enter the January through June 2012 data in the Monitoring data section for each individual month.

General Comprehensive Data System (CDS)

Q: What is the difference between ‘Save’ and ‘Submit’ when I enter my data?

A: ‘Save’ holds your data in a temporary location in the CDS. The data is not available for reports. It may be edited at any time.

‘Submit’ stores your data in permanent tables within the system. It is available for reports and graphs after it is submitted. It may be edited by the hospital for a defined period of time (typically 60 days) after it is submitted.