Specifications Manual for Joint Commission National Quality Measures (v2024A)
Posted: 08/04/2023

Release Notes:
Measure Information Form
Version 2024A


Hospital Based Inpatient Psychiatric Services (HBIPS)

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Set Measures

Set Measure ID Measure Short Name
HBIPS-2 Hours of physical restraint use
HBIPS-3 Hours of seclusion use
HBIPS-5 Patients discharged on multiple antipsychotic medications with appropriate justification

General Data Elements

Element Name Collected For
Admission Date All Records,
Birthdate All Records,
CMS Certification Number All Records,
Discharge Date All Records, Not collected for HBIPS-2 and HBIPS-3
Health Care Organization Identifier All Records,
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, Used in calculation of the Joint Commission's aggregate data.
Payment Source All Records, Optional for HBIPS-2 and HBIPS-3
Psychiatric Care Setting All Records, HBIPS
Race All Records,
Sex All Records,

Algorithm Output Data Elements

Element Name Collected For
Measure Category Assignment All Records, Calculation
Measurement Value Calculation

Measure Set Specific Data Elements

Element Name Collected For
Appropriate Justification for Multiple Antipsychotic Medications HBIPS-5
Discharge Disposition HBIPS-5
Event Date HBIPS-2, HBIPS-3
Event Type HBIPS-2, HBIPS-3
Minutes of Physical Restraint HBIPS-2
Minutes of Seclusion HBIPS-3
Number of Antipsychotic Medications Prescribed at Discharge HBIPS-5
Patient Status at Discharge HBIPS-5
Psychiatric Inpatient Days - Medicare Only HBIPS-2, HBIPS-3
Psychiatric Inpatient Days-Non-Medicare Only HBIPS-2, HBIPS-3
Total Leave Days - Medicare Only HBIPS-2, HBIPS-3
Total Leave Days-Non-Medicare Only HBIPS-2, HBIPS-3

  Document Name  
Acknowledgement  
Appendix A  
Appendix C  
Appendix D - Glossary of Terms  
Appendix E - Overview of Measure Information Form and Flowchart Formats  
Appendix G - Resources  
Appendix H - Miscellaneous Tables  
Cover Page for the Joint Commission Manual  
Data Dictionary  
Introduction to the Manual  
Joint Commission Clinical Data Processing Flow  
Joint Commission National Quality Measures Data Processing  
Missing and Invalid Data  
Sampling  
Table of Contents  
Using the The Joint Commission's National Measure Specifications Manual  





Hospital-Based 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 (HBIPS-5) and the other for event measures (HBIPS-2 and HBIPS-3).

Initial Patient Population for Discharge Measures (HBIPS-5)

The general population of the HBIPS discharge measures can be identified by using four data elements that are common to the discharge performance measures in the HBIPS set:
  • ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes
  • Discharge Date
  • Birthdate
  • Psychiatric Care Setting

The HBIPS Discharge Topic Population is defined as patients discharged from the Psychiatric Care Setting with an ICD-10-CM Principal or Other Diagnosis Code for Mental Disorders as defined in Appendix A, Table 10.01 and a Patient Age at Discharge (Discharge Date -— Birthdate) >= 1 year.

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-5a (overall measures) Age greater than and equal to 1 year The count of all patients in strata 1, 2, 3, and 4
HBIPS-5b Age 1 year through 12 years The count of all patients in stratum 1
HBIPS-5c Age 13 years through 17 years The count of all patients in stratum 2
HBIPS-5d Age 18 years through 64 years The count of all patients in stratum 3
HBIPS-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 years



Initial Patient Population for Event Measures (HBIPS-2 and HBIPS-3)

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 -— Birthdate) >= 1 year and the patient was in a Psychiatric Care Setting (='Y') when the event occurred. There are four distinct strata or sub-populations 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
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 years

HBIPS_Initial_Patient_Pop-v2021A_Page1
HBIPS_Initial_Patient_Pop-v2021A_Page2

HBIPS_Initial_Patient_Pop-v2021A_Page3



HBIPS Initial Patient Population Algorithm Narrative

Variable Key: Patient Age at Discharge, Patient Age at Time of Event, Initial Patient Population Reject Case Flag

1. Start HBIPS Initial Patient Population logic sub-routine. Process all cases that have successfully reached the point in the Data Processing Flow which calls this Initial Patient Population Algorithm. Do not process cases that have been rejected before this point in the Data Processing Flow. Note: Patients that fall into the HBIPS Initial Patient Population are processed as multiple cases. Do not combine multiple events into one case and do not combine event information and discharge information into one case.
2. Event Date:
  1. Date Exists, process as an event case, proceed to step 10.
  2. Date Does Not Exist, potential HBIPS discharge case, proceed to check ICD-10-CM Principal or Other Diagnosis Code
Note: Patients for which an event occurred, and the Event Date is not initially captured electronically must be added to the Event Population during manual data abstraction.
3. Check ICD-10- CM Principal or Other Diagnosis Code
  1. If the ICD-10-CM Principal or Other Diagnosis Code is not on Table 10.01, the patient is not in the HBIPS Discharge Topic Population and patient is not eligible to be sampled for any HBIPS Discharge strata. Set Initial Patient Population Reject Case Flag to equal Yes. Return to Data Processing Flow section.
  2. If the ICD-10-CM Principal or Other Diagnosis Code is on Table 10.01, proceed to Calculate Patient Age at Discharge
4. Calculate Patient Age at Discharge (in years) = Discharge Date - Birthdate. Use the month and day portion of discharge date and birthdate to yield the most accurate age.
5. Check Patient Age at Discharge:
  1. If the Patient Age is equal to zero (0) years, the patient is not in the HBIPS Discharge Topic Population and patient is not eligible to be sampled for any HBIPS Discharge strata. Set Initial Patient Population Reject Case Flag to equal Yes. Return to Data Processing Flow section.
  2. If the Patient Age is greater than or equal to 1 years, proceed to check Psychiatric Care Setting
6. Check Psychiatric Care Setting
  1. If Psychiatric Care Setting is N , the patient is not in the HBIPS Discharge Topic Population and patient is not eligible to be sampled for any HBIPS Discharge strata. Set Initial Patient Population Reject Case Flag to equal Yes. Return to Data Processing Flow section.
  2. If Psychiatric Care Setting is Missing or Y , the patient is in the HBIPS Discharge Topic Population. Set Initial Patient Population Reject Case Flag to equal No, proceed to check Patient Age at Discharge.
7. Check Patient Age at Discharge:
  1. If Patient Age at Discharge is greater than or equal to 1 years and less than 13 years, the patient is in the 1st HBIPS Discharge stratum and patient is eligible to be sampled for the 1st HBIPS Discharge stratum. Include patient in the Initial Patient Population of the appropriate Discharge measures. Return to Data Processing Flow section.
  2. If Patient Age at Discharge is greater than 13 years, continue processing and proceed to check Patient Age at Discharge.
8. Check Patient Age at Discharge:
  1. If Patient Age at Discharge is greater than or equal to 13 years and less than 18 years, the patient is in the 2nd HBIPS Discharge stratum and patient is eligible to be sampled for the 2nd HBIPS Discharge stratum. Include patient in the Initial Patient Population of the appropriate Discharge measures. Return to Data Processing Flow section.
  2. If Patient Age at Discharge is greater than or equal to 18 years, continue processing and proceed to check Patient Age at Discharge.
9. Check Patient Age at Discharge:
  1. If Patient Age at Discharge is greater than or equal to 18 years and less than 65 years, the patient is in the 3rd HBIPS Discharge stratum and patient is eligible to be sampled for the 3rd HBIPS Discharge stratum. Include patient in the Initial Patient Population of the appropriate Discharge measures. Return to Data Processing Flow section.
  2. If Patient Age at Discharge is greater than or equal to 65 years, the patient is in the 4th HBIPS Discharge stratum and patient is eligible to be sampled for the 4th HBIPS Discharge stratum. Include patient in the Initial Patient Population of the appropriate Discharge measures. Return to Data Processing Flow section.
10. Calculate Patient Age at Time of Event (in years) = Event Date - Birthdate. Use the month and day portion of event date and birthdate to yield the most accurate age.
11. Check Patient Age at Time of Event:
  1. If the Patient Age at Time of Event is equal to zero (0) years, the patient is not in the HBIPS Event Topic Population and patient is not eligible for any HBIPS Event strata. Set Initial Patient Population Reject Case Flag to equal Yes. Proceed to check Discharge Date, step 16.
  2. If the Patient Age at Time of Event is greater than or equal to 1 years, proceed to check Psychiatric Care Setting
12. Check Psychiatric Care Setting
  1. If Psychiatric Care Setting is N , the patient is not in the HBIPS Event Topic Population and patient is not eligible for any HBIPS Event strata. Set Initial Patient Population Reject Case Flag to equal Yes. Proceed to check Discharge Date, step 16.
  2. If Psychiatric Care Setting is Y, the patient is in the HBIPS Event Topic Population. Set Initial Patient Population Reject Case Flag to equal No. Proceed to check Patient Age at Time of Event.
Note: Initial Patient Population Size – Medicare Only and Non-Medicare Only for HBIPS Event measures are not derived from those cases that pass through the Initial Patient Population algorithm. Instead, these data are derived from the HBIPS census data calculated by (Psychiatric Inpatient Days - Total Leave Days).
13. Check Patient Age at Time of Event:
  1. If Patient Age at Time of Event is greater than or equal to 1 years and less than 13 years, the patient is in the 1st HBIPS Event stratum and patient is eligible to be sampled for the 1st HBIPS Event stratum. Include patient in the Initial Patient Population of the appropriate Event measures. Proceed to check Discharge Date, step 16.
  2. If Patient Age at Time of Event is greater than 13 years, continue processing and proceed to check Patient Age at Time of Event.
14. Check Patient Age at Time of Event:
  1. If Patient Age at Time of Event is greater than or equal to 13 years and less than 18 years, the patient is in the 2nd HBIPS Event stratum and patient is eligible to be sampled for the 2nd HBIPS Event stratum. Include patient in the Initial Patient Population of the appropriate Event measures. Proceed to check Discharge Date, step 16.
  2. If Patient Age at Time of Event is greater than or equal to 18 years, continue processing and proceed to check Patient Age at Time of Event.
15. Check Patient Age at Time of Event:
  1. If Patient Age at Time of Event is greater than or equal to 18 years and less than 65 years, the patient is in the 3rd HBIPS Event stratum and patient is eligible to be sampled for the 3rd HBIPS Event stratum. Include patient in the Initial Patient Population of the appropriate Event measures. Proceed to check Discharge Date, step 16.
  2. If Patient Age at Time of Event is greater than or equal to 65 years, the patient is in the 4th HBIPS Event stratum and patient is eligible to be sampled for the 4th HBIPS Event stratum. Include patient in the Initial Patient Population of the appropriate Event measures. Proceed to check Discharge Date, step 16.
16. Check Discharge Date:
  1. If Date Exists, potential HBIPS discharge case. Proceed to step 3.
  2. If Date Does Not Exists, not a potential HBIPS discharge case, Return to Data Processing Flow section.
Note: This Discharge Date check exists for those organizations with one data stream for both discharge and event cases. If one case is identified as being in both populations, the data must still be separated into multiple cases for transmission purposes.

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 submitted to the Joint Commission.

Sample Size Requirements for HBIPS Discharge Measures (HBIPS-5)
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 (HBIPS-DSC) Measures
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

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 (HBIPS-DSC) Measures
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

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 HBIPS-5b 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.

  • 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 or 20% of population 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 for each stratum 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 Requirements for HBIPS Event Measures (HBIPS-2 and HBIPS-3)

The measures in HBIPS-EVT (HBIPS-2 and HBIPS-3) are not eligible for sampling and will use the entire Initial Patient Population for reporting.

Measure Information Form HBIPS
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Specifications Manual for Joint Commission National Quality Measures (v2024A)
Discharges 01-01-24 (1Q24) through 06-30-24 (2Q24)

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