Set Measure ID | Measure Short Name |
---|---|
HBIPS-1 | Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths completed |
HBIPS-2 | Hours of physical restraint use |
HBIPS-3 | Hours of seclusion use |
HBIPS-5 | 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 HBIPS-2 and HBIPS-3 |
Health Care Organization Identifier | All Records, Patient Population Data File, Hospital Clinical Data File, |
Hispanic Ethnicity | All Records, |
ICD-10-CM Other Diagnosis Codes | All Records, Optional for HBIPS-2, HBIPS-3 |
ICD-10-CM Principal Diagnosis Code | All Records, Optional for HBIPS-2, HBIPS-3 |
ICD-10-PCS Other Procedure Codes | All Records, Optional for All HBIPS Records |
ICD-10-PCS Other Procedure Dates | All Records, Optional for All HBIPS Records |
ICD-10-PCS Principal Procedure Code | All Records, Optional for All HBIPS Records |
ICD-10-PCS 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. |
Payment Source | All Records, Optional for HBIPS-2 and HBIPS-3 |
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 |
Document Name |
---|
The HBIPS measure set is unique in that there are two distinct Initial Patient Populations within the measure set, one for the discharge measures (HBIPS-1, HBIPS-5) and the other for event measures (HBIPS-2 and HBIPS-3).
Initial Patient Population for Discharge Measures (HBIPS-1, HBIPS-5)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 |
---|---|---|
HBIPS-1a and 5a (overall measures) | Age greater than and equal to 1 year | The count of all patients in strata 1, 2, 3, and 4 |
HBIPS-1b and 5b | Age 1 year through 12 years | The count of all patients in stratum 1 |
HBIPS-1c and 5c | Age 13 years through 17 years | The count of all patients in stratum 2 |
HBIPS-1d and 5d | Age 18 years through 64 years | The count of all patients in stratum 3 |
HBIPS-1e 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 ICD-10-CM 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 |
---|---|---|
HBIPS-2a and 3a (overall measures) | Age greater than and equal to 1 year | The count of all patients in strata 1, 2, 3, and 4 |
HBIPS-2b and 3b | Age 1 year through 12 years | The count of all patients in stratum 1 |
HBIPS-2c and 3c | Age 13 years through 17 years | The count of all patients in stratum 2 |
HBIPS-2d and 3d | Age 18 years through 64 years | The count of all patients in stratum 3 |
HBIPS-2e 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 HBIPS-1b as an example, include cases covering all sampled strata, although the measure-specific exclusion criteria would only allow cases with an age of 1 year through 12 years to be included in the denominator.