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ePC-07 Severe Obstetric Complications

CBE ID
3687e
Endorsement Status
1.1 New or Maintenance
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Spring 2028
E&M Cycle Comments

Effective March 27, 2023, the National Quality Forum (NQF) is no longer the consensus-based entity (CBE) funded through the Centers for Medicare & Medicaid Services (CMS) National Consensus Development and Strategic Planning for Health Care Quality Measurement Contract. Battelle has been selected to oversee the endorsement & maintenance (E&M) of clinical quality and cost/resource use measures. Since the Spring 2023 cycle launched at NQF, measures submitted to this E&M cycle continued along the prior E&M protocols that were in place at time of the Spring 2023 “Intent to Submit.” Battelle took over the E&M work for the Spring 2023 cycle when developers and/or stewards submitted their full measure information, which for CBE #3687e, the most recent measure specifications can be found here: https://p4qm.org/sites/default/files/2023-06/3687e_severe_obstetric_complications.zip

To close out this E&M cycle, Battelle published the Spring 2023 measures for pre-evaluation public commenting, convened the E&M standing committees for their measure evaluation meetings, launched the Spring 2023 post-comment period, convened the E&M committees for the post-comment meeting, convened the CSAC to render a final endorsement decision, and executed the appeals period.

 

1.3 Measure Description

Hospital-level measure scores are calculated as a risk-adjusted proportion of the number of delivery hospitalizations for women who experience a severe obstetric complication, as defined by the numerator, by the total number of delivery hospitalizations in the denominator during the measurement period.

        • 1.14 Numerator

          Inpatient hospitalizations for patients with severe obstetric complications including severe maternal morbidity diagnoses, severe maternal morbidity procedures, discharge disposition = expired.

        • 1.15 Denominator

           Inpatient hospitalizations for patients delivering stillborn or live birth with >= 20 weeks, 0 days gestation completed.

        • Exclusions

          Patients with confirmed diagnosis of COVID with COVID-related respiratory condition or patients with confirmed diagnosis of COVID with COVID-related respiratory procedure.

        • OLD 1.12 MAT output not attached
          Attached
          1.13a Data dictionary not attached
          No
        • Most Recent Endorsement Activity
          Patient Safety Spring 2023
        • Steward
          The Joint Commission
          Steward Organization POC Email
              • Risk Adjustment
                Risk adjustment approach
                Off
                Risk adjustment approach
                Off
                Conceptual model for risk adjustment
                Off
                Conceptual model for risk adjustment
                Off