Measure Information Form
**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**
Measure Information Form
Measure Set: Hospital Based Inpatient Psychiatric Services (HBIPS)
Set Measure ID: HBIPS-3
Performance Measure Name: Hours of seclusion use
Description: The total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were held in seclusion.
Rationale: Mental health providers that value and respect an individuals autonomy, independence and safety seek to avoid the use of dangerous or restrictive interventions at all times (Donat, 2003). The use of seclusion and restraint is limited to situations deemed to meet the threshold of imminent danger and when restraint or seclusion are used; such use is rigorously monitored and analyzed to prevent future use. Providers also seek to prevent violence or aggression from occurring in their treatment environments by focusing their attention on prevention activities that have a growing evidence base (Donat, 2003).
Type of Measure: Process
Improvement Noted As: Decrease in the rate
| Set Measure ID
|| Performance Measure Name
|| Seclusion- Overall Rate
|| Seclusion- Children (1 through 12 years)
|| Seclusion- Adolescent (13 through 17 years)
|| Seclusion- Adult (18 through 64 years)
|| Seclusion- Older Adult (≥ 65 years)
| Numerator Statement:
Risk Adjustment: No.
Data Collection Approach: Retrospective data sources for required data elements include administrative/billing data and medical records.
Data Accuracy: Hospitals may wish to implement periodic audits to monitor and ensure data accuracy.
Measure Analysis Suggestions: In order to further examine the issue of seclusion use within your facility it may be useful to study the incidence of seclusion use by collecting additional information about the clinical justification for use.
Data Reported As: Aggregate rate generated from count data reported as a ratio .
The total number of hours that all psychiatric inpatients were held in seclusion Numerator Basis
: The numerator evaluates the number of hours of seclusion; however, the algorithm calculates the number of minutes to ensure a more accurate calculation of the measure. Convert the minutes to hours when analyzing and reporting this measure.
Excluded Populations: None
- Patients for whom at least one seclusion event is reported during the month
Number of psychiatric inpatient days Denominator Basis
: per 1,000 hours
- All psychiatric inpatient days
Adopted for CMS Inpatient Psychiatric Facility Quality Reporting Program FY 2014
- Donat, D. (August, 2003). An analysis of successful efforts to reduce the use of seclusion and restraint at a public psychiatric hospital. Psychiatric Services. 54(8): 1119-1123.
- Fisher, W. A. (2003). Elements of successful restraint and seclusion reduction programs and their application in a large, urban, state psychiatric hospital. Journal of Psychiatric Practice, 9(1), 7-15.
- Huckshorn, K.A. (2004/September). Reducing seclusion and restraint use in mental health settings: Core strategies for prevention. Journal of Psychosocial Nursing and Mental Health Services. 42(9). Pp. 22-31.
- Mohr, W. K., & Anderson, J. A. (2001). Faulty assumptions associated with the use of restraints with children. Journal of Child and Adolescent Psychiatric Nursing, 14(3), 141- 151.
- Special Section on Seclusion and Restraint, (2005, Sept). Psychiatric Services, 56 (9), 1104-1142.
- Success Stories and Ideas for Reducing Restraint/Seclusion. (2003). A compendium of strategies created by the American Psychiatric Association (APA), the American Psychiatric Nurses Association (APNA), the National Association of Psychiatric Health Systems (NAPHS), and the American Hospital Association Section for Psychiatric and Substance Abuse Services (AHA). Retrieved from the Internet on February 10, 2010 at http://www.naphs.org