Release Notes:
Measure Information Form
Version 2014A1
Hospital Based Inpatient Psychiatric Services (HBIPS)
Set Measures
Set Measure ID 
Measure Short Name 
HBIPS1 
Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths completed 
HBIPS2 
Hours of physical restraint use 
HBIPS3 
Hours of seclusion use 
HBIPS4 
Patients discharged on multiple antipsychotic medications 
HBIPS5 
Patients discharged on multiple antipsychotic medications with appropriate justification 
HBIPS6 
Post discharge continuing care plan created 
HBIPS7 
Post discharge continuing care plan transmitted to next level of care provider upon discharge 
General Data Elements
Element Name 
Collected For 
Birthdate 
All Records, 
CMS Certification Number 
Hospital Clinical Data File, Optional for All Records, 
Discharge Date 
All Records, Not collected for HBIPS2 and HBIPS3 
Event Date 
All Records, Not collected for HBIPS1, 4, 5, 6 and 7 
Event Type 
All Records, Not collected for HBIPS1, 4, 5, 6 and 7 
Health Care Organization Identifier 
All Records, Aggregate Data File, Patient Population Data File, Hospital Clinical Data File, 
Hispanic Ethnicity 
All Records, 
ICD9CM Other Diagnosis Codes 
All Records, Optional for HBIPS2, HBIPS3 and PBM; Used in algorithm for PC01, 02, 03, 04, and 05 
ICD9CM Other Procedure Codes 
All Records, Optional for All HBIPS Records; Used in algorithm for PC01, 02, 04 and 05; 
ICD9CM Other Procedure Dates 
All Records, Optional for All HBIPS and PBM Records 
ICD9CM Principal Diagnosis Code 
All Records, Optional for HBIPS2 and HBIPS3; Used in algorithm for PC01, 02, 03, 04, 05 and PBM03 
ICD9CM Principal Procedure Code 
All Records, Optional for All HBIPS Records; Used in algorithm for PC01, 02, 04 and 05 
ICD9CM Principal Procedure Date 
All Records, Optional for All HBIPS and PBM Records 
Payment Source 
All Records, Optional for HBIPS2 and HBIPS3 
Psychiatric Care Setting 
All Records, 
Race 
All Records, 
Sex 
All Records, 
Algorithm Output Data Elements
Measure Set Specific Data Elements
Element Name 
Collected For 
Admission Date 
HBIPS, 
Appropriate Justification for Multiple Antipsychotic Medications 
HBIPS5, 
Continuing Care PlanDischarge Medications 
HBIPS6, HBIPS7, 
Continuing Care PlanNext Level of Care 
HBIPS6, HBIPS7, 
Continuing Care PlanPrincipal Discharge Diagnosis 
HBIPS6, HBIPS7, 
Continuing Care PlanReason for Hospitalization 
HBIPS6, HBIPS7, 
Discharge Disposition 
HBIPS4, HBIPS5, HBIPS6, HBIPS7, 
Minutes of Physical Restraint 
HBIPS2, 
Minutes of Seclusion 
HBIPS3, 
Number of Antipsychotic Medications Prescribed at Discharge 
HBIPS4, HBIPS5, 
Patient Referral to Next Level of Care Provider 
HBIPS4, HBIPS5, HBIPS6, HBIPS7, 
Patient Strengths 
HBIPS1, 
Psychiatric Inpatient Days  Medicare Only 
HBIPS2, HBIPS3, 
Psychiatric Inpatient DaysNonMedicare Only 
HBIPS2, HBIPS3, 
Psychological Trauma History 
HBIPS1, 
Substance Use 
HBIPS1, 
Total Leave Days  Medicare Only 
HBIPS2, HBIPS3, 
Total Leave DaysNonMedicare Only 
HBIPS2, HBIPS3, 
Violence Risk to Others 
HBIPS1, 
Violence Risk to Self 
HBIPS1, 
Related Materials
HospitalBased Inpatient Psychiatric Services (HBIPS) Measure Set Initial Patient Population
The HBIPS measure set is unique in that there are two distinct Initial Patient Populations within the measure set, one for the discharge measures (HBIPS1, HBIPS4, HBIPS5, HBIPS6, and HBIPS7) and the other for event measures (HBIPS2 and HBIPS3).
Initial Patient Population for Discharge Measures (HBIPS1, HBIPS4, HBIPS5, HBIPS6, and HBIPS7)
The population of the HBIPS discharge measures can be identified by using three data elements that are common to the discharge performance measures in the HBIPS set:
 ICD9CM Principal Diagnosis Code or ICD9CM Other Diagnosis Codes
 Discharge DateHBIPS
 BirthdateHBIPS
The HBIPS Discharge Topic Population is defined as patients discharged from the hospital with an ICD9CM Principal or Other Diagnosis Code for Psychiatric Services as defined in Appendix A, Table 10.01 and a Patient Age at Discharge (Discharge DateHBIPS – BirthdateHBIPS) >= 1 year. There are four distinct strata or subpopulations within the HBIPS Discharge Topic Population, each identified by a specific age range. The patients in each stratum are counted in the HBIPS Initial Patient Population for discharge measures of multiple measures.
Discharge Measures 
Age Strata 
Initial Patient Population definition 
HBIPS1a, 4a, 5a, 6a, and 7a (overall measures) 
Age greater than and equal to 1 year 
The count of all patients in strata 1, 2, 3, and 4 
HBIPS1b, 4b, 5b, 6b, and 7b 
Age 1 year through 12 years 
The count of all patients in stratum 1 
HBIPS1c, 4c, 5c, 6c, and 7c 
Age 13 years through 17 years 
The count of all patients in stratum 2 
HBIPS1d, 4d, 5d, 6d, and 7d 
Age 18 years through 64 years 
The count of all patients in stratum 3 
HBIPS1e, 4e, 5e, 6e, and 7e 
Age greater than and equal to 65 years 
The count of all patients in stratum 4 
Patients discharged from the hospital with an ICD9CM Principal or Other Diagnosis Code for Psychiatric Services as defined in Appendix A, Table 10.01 are included in one of the HBIPS Strata Initial Populations for discharge measures and are eligible to be sampled if they have:
Discharge Stratum 1 – Age 1 year through 12 years stratum – A Patient Age at Discharge (Discharge DateHBIPS – BirthdateHBIPS) >= 1 year and < 13 years
Discharge Stratum 2  Age 13 years through 17 years stratum – A Patient Age at Discharge (Discharge DateHBIPS – BirthdateHBIPS) >= 13 years and < 18 years
Discharge Stratum 3  Age 18 years through 64 years stratum – A Patient Age at Discharge (Discharge DateHBIPS – BirthdateHBIPS) >= 18 years and < 65 years
Discharge Stratum 4  Age greater than and equal to 65 years stratum – A Patient Age at Discharge (Discharge DateHBIPS – BirthdateHBIPS) >= 65 years
Initial Patient Population for Event Measures (HBIPS2 and HBIPS3)
The population of the HBIPS event measures can be identified by using two data elements that are common to the event performance measures in the HBIPS set:
 Event Date
 Psychiatric Care Setting
The HBIPS Event Topic Population (common to all HBIPS event measures) is defined as patients with an event (Event Date exists) while they are in the hospital with a Patient Age at Time of Event (Event Date – BirthdateHBIPS) >= 1 year and the patient was in a Psychiatric Care Setting (=’Y’) when the event occurred. There are four distinct strata or subpopulations within the HBIPS Event Topic Population, each identified by a specific age range. The patients in each stratum are counted in the HBIPS Initial Patient Population for event measures of multiple measures.
Event Measures 
Age Strata 
Initial Patient Population definition 
HBIPS2a and 3a (overall measures) 
Age greater than and equal to 1 year 
The count of all patients in strata 1, 2, 3, and 4 
HBIPS2b and 3b 
Age 1 year through 12 years 
The count of all patients in stratum 1 
HBIPS2c and 3c 
Age 13 years through 17 years 
The count of all patients in stratum 2 
HBIPS2d and 3d 
Age 18 years through 64 years 
The count of all patients in stratum 3 
HBIPS2e and 3e 
Age greater than and equal to 65 years 
The count of all patients in stratum 4 
Patients for which an event occurs (Event Date exists) while in a Psychiatric Care Setting (=’Y’) in the hospital are included in one of the Strata Initial Populations for the event measures. There is no sampling for the HBIPS event measures. All patients in the Initial Population for HBIPS event measures are automatically sampled.
Event Stratum 1 – Age 1 year through 12 years stratum – A Patient Age at Time of Event (Event Date – BirthdateHBIPS) >= 1 year and < 13 years
Event Stratum 2  Age 13 years through 17 years stratum – A Patient Age at Time of Event (Event Date – BirthdateHBIPS) >= 13 years and < 18 years
Event Stratum 3  Age 18 years through 64 years stratum – A Patient Age at Time of Event (Event Date – BirthdateHBIPS) >= 18 years and < 65 years
Event Stratum 4  Age greater than and equal to 65 years stratum – A Patient Age at Time of Event (Event Date – BirthdateHBIPS) >= 65 years
Sample Size Requirements
Note For Joint Commission purposes, the HBIPS measure set is not included in the aligned Global Sampling methodology. All patients meeting the definition of the HBIPS Initial Patient Populations are eligible to be sampled, abstracted, and transmitted to the Joint Commission’s Data Warehouse.
Sample Size Requirements for HBIPS Discharge Measures (HBIPS1, HBIPS4, HBIPS5, HBIPS6, and HBIPS7)
Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may choose to use a larger sample size than is required. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter/month for the stratum cannot sample that stratum.
Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. Because the sample for a measure set will rarely be equal to the effective sample due to exclusions and contraindications, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size.
The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual.
Quarterly Sampling
For hospitals selecting sample cases for the HBIPS discharge measures, a modified sampling procedure is required. Hospitals selecting sample cases for this set must ensure that each individual stratum’s population and effective quarterly sample size meets the following conditions:
 Select within each of the four individual measure strata. The effective quarterly sample size within a stratum is at least 44 cases per quarter. Cases are placed into the appropriate stratum based upon the patient’s age.
 The required quarterly sample size is at least 20% of the stratum population for the quarter.
Quarterly Sample Size
Based on Initial Patient Population for the HBIPS Discharge Measures
Monthly Sampling
For hospitals selecting sample cases for HBIPS discharge measures, a modified sampling procedure is required. Hospitals selecting sample cases for this set must ensure that each individual strata population and effective monthly sample size meets the following conditions:
 Select within each of the four individual measure strata. The effective monthly sample size within a stratum is at least 15 cases per month. Cases are placed into the appropriate stratum based upon the patient’s age.
 The required monthly sample size is at least 20% of the stratum population for the month.
Monthly Sample Size
Based on Initial Patient Population for the HBIPS Discharge Measures
Sample Size Examples
All sampled strata in HBIPS should be used in the calculation of all HBIPS discharge measures. All of the HBIPS discharge measures' specific exclusion criteria are used to filter out cases that do not belong in the measure denominator. Using HBIPS1b as an example, include cases covering all sampled strata, although the measurespecific exclusion criteria would only allow cases with an age of 1 year through 12 years to be included in the denominator.
 Quarterly sampling:
When applicable, larger hospitals must also abide by the required quarterly sample sizes for the four individual measure strata a minimum of 44 required sample cases per stratum when Initial Patient Population size is 44 or greater.
 The HBIPS Initial Patient Population sizes for a hospital are 5, 100, 221, and 876 patients respectively per quarter. The required quarterly sample sizes would be 5, 44, 45, and 176.
 The 1st stratum is less than the minimum required quarterly sample size, so 100% of this stratum is sampled.
 The 2nd stratum has 100 patients per quarter, which falls in the average quarterly population size of 44 to 220 patients, so 44 cases are sampled.
 The 3rd stratum has 221 patients per quarter, which requires a 20% sample size, of 45 cases (twenty percent of 221 equals 44.2 rounded to the next highest whole number = 45).
 The 4th stratum has 876 patients per quarter, which is more than the maximum condition, so a minimum of 176 cases are required to be sampled.
 Monthly sampling:
When applicable, larger hospitals must also abide by the required monthly sample sizes for the four individual measure strata a minimum of 15 required sample cases per stratum when Initial Patient Population size is 15 or greater.
 The HBIPS Initial Patient Population sizes for a hospital are 5, 45, 294 and 400 patients respectively in July. The required monthly sample sizes would be 5, 15, 59, and 60.
 The 1st stratum is less than the minimum required monthly sample size, so 100% of this stratum is sampled.
 The 2nd stratum has 45 patients per month, which falls in the average monthly population size of 15 to 75 patients, so 15 cases are sampled.
 The 3rd stratum has 294 patients per month, which requires a 20% sample size, of 59 cases (twenty percent of 294 equals 58.8 rounded to the next highest whole number = 59).
 The 4th stratum has 400 patients per month, which is more than the maximum condition, so a minimum of 60 cases are required to be sampled.
Sampling Size Requirements for HBIPS Event Measures (HBIPS2 and HBIPS3)
The measures HBIPS2 and HBIPS3 are not eligible for sampling and will use the entire Initial Patient Population for reporting.
