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 
HBIPS5  Patients discharged on multiple antipsychotic medications with appropriate justification 
Element Name  Collected For 

Admission Date  All Records, 
Birthdate  All Records, 
CMS Certification Number  Transmission, Hospital Clinical Data File, Optional for All Records, 
Discharge Date  All Records, Not collected for HBIPS2 and HBIPS3 
Health Care Organization Identifier  All Records, Patient Population Data File, Hospital Clinical Data File, 
Hispanic Ethnicity  All Records, 
ICD10CM Other Diagnosis Codes  All Records, Optional for HBIPS2, HBIPS3 
ICD10CM Principal Diagnosis Code  All Records, Optional for HBIPS2, HBIPS3 
ICD10PCS Other Procedure Codes  All Records, Optional for All HBIPS Records 
ICD10PCS Other Procedure Dates  All Records, Optional for All HBIPS Records 
ICD10PCS Principal Procedure Code  All Records, Optional for All HBIPS Records 
ICD10PCS Principal Procedure Date  All Records, Optional for All HBIPS Records 
Measure Category Assignment  All Records, Calculation, Transmission, Hospital Clinical Data File, Used in calculation of the Joint Commission's aggregate data and in the transmission of the Hospital Clinical Data file. Informational ONLY for PBM. Notes:

Payment Source  All Records, Optional for HBIPS2 and HBIPS3 
Psychiatric Care Setting  All Records, HBIPS 
Race  All Records, 
Sex  All Records, 
Vendor Tracking Identifier  All Records, Transmission, Hospital Clinical Data File, 
Element Name  Collected For 

Measure Category Assignment  All Records, Calculation, Transmission, Hospital Clinical Data File 
Measurement Value  Calculation, Transmission, Hospital Clinical Data File 
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, HBIPS5) and the other for event measures (HBIPS2 and HBIPS3).
Initial Patient Population for Discharge Measures (HBIPS1, HBIPS5)There are four distinct strata within the HBIPS Discharge Topic Population; each is 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 and 5a (overall measures)  Age greater than and equal to 1 year  The count of all patients in strata 1, 2, 3, and 4 
HBIPS1b and 5b  Age 1 year through 12 years  The count of all patients in stratum 1 
HBIPS1c and 5c  Age 13 years through 17 years  The count of all patients in stratum 2 
HBIPS1d and 5d  Age 18 years through 64 years  The count of all patients in stratum 3 
HBIPS1e and 5e  Age greater than and equal to 65 years  The count of all patients in stratum 4 
Patients discharged from the hospital with an ICD10CM Principal or Other Diagnosis Code for Mental Disorders 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 Date — Birthdate) >= 1 year and < 13 years Discharge Stratum 2  Age 13 years through 17 years stratum — A Patient Age at Discharge (Discharge Date — Birthdate) >= 13 years and < 18 years Discharge Stratum 3  Age 18 years through 64 years stratum — A Patient Age at Discharge (Discharge Date — Birthdate) >= 18 years and < 65 years Discharge Stratum 4  Age greater than and equal to 65 years stratum — A Patient Age at Discharge (Discharge Date — Birthdate) >= 65 yearsEvent 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 — Birthdate) >= 1 year and < 13 years Event Stratum 2  Age 13 years through 17 years stratum — A Patient Age at Time of Event (Event Date — Birthdate) >= 13 years and < 18 years Event Stratum 3  Age 18 years through 64 years stratum — A Patient Age at Time of Event (Event Date — Birthdate) >= 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 — Birthdate) >= 65 yearsRegardless 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.
Hospital's Measures  

Average Quarterly Stratum Initial Patient Population Size “N” 
Minimum Required Stratum Sample Size “n” 
> 877  176 
221 — 877  20% of the Initial Patient Population 
44 — 220  44 
< 44  No sampling; 100% of the Initial Patient Population is required 
Hospital's Measures  

Average Monthly Stratum Initial Patient Population Size “N” 
Minimum Required Stratum Sample Size “n” 
> 295  60 
76 — 295  20% of the Initial Patient Population 
15 — 75  15 
< 15  No sampling; 100% of the Initial Patient Population is required 
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.