Measure Information Form

Measure Set: Hospital Based Inpatient Psychiatric Services (HBIPS)

Set Measure ID: HBIPS-1

Set Measure ID	Performance Measure Name
HBIPS-1a	Admission Screening- Overall Rate
HBIPS-1b	Admission Screening- Children (1 through 12 years)
HBIPS-1c	Admission Screening- Adolescent (13 through 17 years)
HBIPS-1d	Admission Screening- Adult (18 through 64 years)
HBIPS-1e	Admission Screening- Older Adult (≥65 years)

Performance Measure Name: Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths completed

Description: Patients admitted to a hospital-based inpatient psychiatric setting who are screened within the first three days of admission for all of the following: risk of violence to self or others, substance use, psychological trauma history and patient strengths.

Rationale: Substantial evidence exists that there is a high prevalence of co-occurring substance use disorders as well as history of trauma among persons admitted to acute psychiatric settings. Professional literature suggests that these factors are under-identified yet integral to current psychiatric status and should be assessed in order to develop appropriate treatment (Ziedonis, 2004; NASMHPD, 2005). Similarly, persons admitted to inpatient settings require a careful assessment of risk for violence and the use of seclusion and restraint. Careful assessment of risk is critical to safety and treatment. Effective, individualized treatment relies on assessments that explicitly recognize patients' strengths. These strengths may be characteristics of the individuals themselves, supports provided by families and others, or contributions made by the individuals' community or cultural environment (Rapp, 1998). In the same way, inpatient environments require assessment for factors that lead to conflict or less than optimal outcomes.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Psychiatric inpatients with admission screening within the first three days of admission for all of the following: risk of violence to self or others; substance use; psychological trauma history; and patient strengths

Included Populations: Not applicable
Excluded Populations: None
Data Elements:

Patient Strengths

Psychological Trauma History

Substance Use

Violence Risk to Others

Violence Risk to Self

Denominator Statement: Psychiatric inpatient discharges

Included Populations:

Patients with ICD-10-CM Principal or Other Diagnosis Codes for Mental Disorders as defined in Appendix A, Table 10.01

Excluded Populations:

Patients for whom there is an inability to complete admission screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths within the first three days of admission

Patients with a Length of Stay ≤ 3 days or ≥ 365 days

Data Elements:

Admission Date

Birthdate

Discharge Date

ICD-10-CM Other Diagnosis Codes

ICD-10-CM Principal Diagnosis Code

Psychiatric Care Setting

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: The data elements for each of the five initial assessment elements provide an opportunity to assess each component individually. However, completion of all five initial assessment categories is required for this measure.

Sampling: Yes. For additional information see the Sampling Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

American Psychiatric Association (2016). Practice Guidelines for the Psychiatric Evaluation of Adults. Third edition. Arlington (VA): American Psychiatric Association.
Lyons JS, Uziel-Miller ND, Reyes F, Sokol PT (2000). Strengths of children and adolescents in residential settings: Prevalence and associations with psychopathology and discharge placement. Journal of the American Academy of Child & Adolescent Psychiatry, Vol 39(2): 176-181.
NASMHPD. (2005) Position Statement on Services and Supports to Trauma Survivors. Alexandria, VA: NASMHPD.
Rapp CA (1998). The strengths model: Case management with people suffering from severe and persistent mental illness. London: Oxford University Press.
Ruiz P (2004). Addressing Culture, Race, & Ethnicity in Psychiatric Practice. Psychiatric Annals, Vol 34(7): 527-532.
Ziedonis DM (2004). Integrated treatment of co-occurring mental illness and addiction: Clinical intervention, program, and system perspectives. CNS Spectrums 9(12): 892,894-904,925.

Measure Algorithm:

Specifications Manual for Joint Commission National Quality Measures (v2023A)
Discharges 01-01-23 (1Q23) through 06-30-23 (2Q23)

LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.