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

Release Notes:
Measure Information Form
Version 2024A

Measure Information Form

Measure Set: Hospital Based Inpatient Psychiatric Services (HBIPS)

Set Measure ID: HBIPS-5

Set Measure ID Performance Measure Name
HBIPS-5a viewtopic Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Overall Rate
HBIPS-5b viewtopic Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Children (1 through 12 years)
HBIPS-5c viewtopic Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Adolescent (13 through 17 years)
HBIPS-5d viewtopic Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Adult (18 through 64 years)
HBIPS-5e viewtopic Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Older Adult (≥ 65 years)

Performance Measure Name: Patients discharged on multiple antipsychotic medications with appropriate justification

Description: Patients discharged from a hospital-based inpatient psychiatric setting on two or more antipsychotic medications with appropriate justification

Rationale: Research studies have found that 4-35% of outpatients and 30-50% of inpatients treated with an antipsychotic medication concurrently received 2 or more antipsychotics (Covell, Jackson, Evans, & Essock, 2002; Ganguly, Kotzan, Miller, Kennedy, & Martin, 2004; Gilmer, Dolder, Folsom, Mastin, & Jeste, 2007; Kreyenbuhl, Valenstein, McCarthy, Ganocyz, & Blow, 2006; Stahl & Grady, 2004). One study reported 4.6% of patients concurrently received 3 or more antipsychotics (Jaffe & Levine, 2003). These findings are seen across diverse sectors: state mental health authorities, the Veterans Health System and Medicaid-financed care. Antipsychotic polypharmacy can lead to greater side effects, often without improving clinical outcomes (Ananth, Parameswaran, & Gunatilake, 2004; Stahl & Grady, 2004). As a result, a range of stakeholders have called for efforts to reduce unnecessary use of multiple antipsychotics (Centorrino, Gören, Hennen, Salvatore, Kelleher, & Baldessarini, 2004; Gilmer, Dolder, Folsom, Mastin, & Jeste, 2007; National Association of State Mental Health Program Directors, 2001; University HealthSystem Consortium, 2006). Practice guidelines recommend the use of a second antipsychotic only after multiple trials of a single antipsychotic have proven inadequate (American Psychiatric Association [APA] Practice Guidelines, 2004). Randomized controlled trials (RCTs) provide some evidence to support augmentation with a second antipsychotic in treatment resistant patients. Most of these studies were limited to augmentation of clozapine with another second-generation antipsychotic (Tranulis, Skalli, Lalonde, & Nicole, 2008). Among patients without a documented history of previous treatment failures of antipsychotic monotherapy, multiple RCTs and other controlled trials failed to show a benefit of antipsychotic polypharmacy over monotherapy (Ananth, Parameswaran, & Gunatilake, 2004; Centorrino, Gören, Hennen, Salvatore, Kelleher, & Baldessarini, 2004; Potkin, Thyrum, Alva, Bera, Yeh, & Arvanitis, 2002; Shim et al., 2007; Stahl,& Grady, 2004). Clinical circumstances, such as shorter inpatient stays, may require hospitals to discharge a patient on multiple antipsychotics with an aftercare plan to transition to monotherapy. In such cases, effective communication between the inpatient and aftercare clinician is an essential element of care.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Psychiatric inpatients discharged on two or more routinely scheduled antipsychotic medications with appropriate justification
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

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 discharged on two or more routinely scheduled antipsychotic medications (refer to Appendix C, Table 10.0- Antipsychotic Medications).

Excluded Populations:
  • Patients who expired
  • Patients with an unplanned departure resulting in discharge due to elopement
  • Patients with an unplanned departure resulting in discharge due to failing to return from leave
  • Patients with a length of stay ≤ 3 days

Data Elements:

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: For quality improvement purposes, the measurement system may want to create reports to identify patients discharged on two or more antipsychotic medications without appropriate supporting documentation. This would allow healthcare organizations to target education efforts.

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 (APA). (2004). Steering Committee on Practice Guidelines. Practice guideline for the treatment of patients with schizophrenia, second edition. Am J Psychiatry. 161(2 Suppl):1-56
  • Ananth, J., Parameswaran, S., & Gunatilake, S. (2004). Antipsychotic polypharmacy comparing monotherapy with polypharmacy and augmentation. Curr Med Chem. 11(3):313-327 Curr Pharm Des. 10(18):2231-2238.
  • Centorrino, F., Gören, J.L., Hennen, J., Salvatore, P., Kelleher, J.P., & Baldessarini, R.J. (2004) Multiple versus single antipsychotic agents for hospitalized psychiatric patients: a case control study of risk versus benefit. Am J Psychiatry. 161 (4):700-706.
  • Covell, N.H., Jackson, C.T., Evans, A.C., & Essock, S.M. (2002). Antipsychotic prescribing practices in Connecticut's public mental health system: rates of changing medication prescribing styles. Schiz Bull. 28(1):17-29,
  • Ganguly, R., Kotzan, J.A., Miller, L.S., Kennedy, K., & Martin, B.C. (2004). Prevalence, trends, and factors associated with antipsychotic polypharmacy among Medicaid-eligible schizophrenia patients, 1998-2000. J Clin Psychiatry. 65(10):1377-88.
  • Gilmer, T.P., Dolder, C.R., Folsom, D.P., Mastin, W., & Jeste, D.V. (2007), Antipsychotic polypharmacy trends among Medicaid beneficiaries with schizophrenia in San Diego County, 1999 - 2004. Psychiatric Serv. 59(7):1007-1010.
  • Jaffe, A.B. & Levine, J. (2003). Antipsychotic medication co-prescribing in a large state hospital system. Pharmacoepidemiol Drug Saf.12:41-48.
  • Kreyenbuhl, J., Valenstein, M., McCarthy, J.F., Ganocyz, D., & Blow, F.C. (2006). Long-term combination antipsychotic treatment in VA patients with schizophrenia. Schiz Res.84:90-99.
  • National Association of State Mental Health Program Directors (NASMHPD). (2001).Technical report on psychiatric polypharmacy. Alexandria, VA.
  • Potkin, S.G., Thyrum, P.T., Alva, G., Bera, R., Yeh, C., & Arvanitis, L.A. (2002). The safety and pharmacokinetics of quetiapine when coadministered with haloperidol, risperidone or thioridazine. J Clin Psychopharmacol. 22:121-130.
  • Shim, J.C., Shin, J.G., Kelly, D.L., Jung, D.U., Seo, Y.S., Liu, K.H., et al. (2007). Adjunctive treatment with a dopamine partial agonist aripiprazole, for treatment of antipsychotic-induced hyperprolactinemia: A placebo controlled trial. Am J Psych.164:1404-1410.
  • Stahl, S.M. & Grady, M.M. (2004). A critical review of atypical antipsychotic utilization: comparing monotherapy with polypharmacy augmentation. Curr Med Chem.11:313-327.
  • Tranulis, C., Skalli, L., Lalonde, P., & Nicole, L. (2008). Benefits and risks of antipsychotic polypharmacy. An evidence based review of the literature. Drug Saf.31(1):7-20
  • University HealthSystem Consortium. (2006). Mental health performance measures field brief. Oakbrook, IL.

Measure Algorithm:
HBIPS-5_Page1 HBIPS-5_Page2



HBIPS-5: Patients discharged on multiple antipsychotic medications with appropriate justification
Algorithm Narrative


Numerator: Psychiatric inpatients discharged on two or more routinely scheduled antipsychotic medications with appropriate justification
Denominator: Psychiatric inpatient who are discharged on two or more routinely scheduled antipsychotic medications

Variable key: Patient Age at Time of Event

Stratified Measure Name:
HBIPS-5a Overall Rate
HBIPS-5b Children1-12 years
HBIPS-5c Adolescent 13-17 years
HBIPS-5d Adult 18-64 years
HBIPS-5e Older Adult >=65 years.

1. Run cases, which are included in the Inpatient Initial Patient Population for HBIPS Discharge Measures and pass the edits defined in the Clinical Data Processing Flow, through this measure.

2. Calculate Length of Stay. Length of Stay, in days, is equal to the Discharge Date minus the Admission Date.

3. Check Length of Stay

a. If Length of Stay is less than or equal to 3 days, the case will proceed to a Measure Category Assignment of B for Overall Rate (HBIPS-5a) and will not be in the measure population. Continue processing and proceed to step 10 and initialize the Measure Category Assignment for each strata measure.
b. If Length of Stay is greater than 3 days, continue processing and proceed to check Discharge Disposition.

4. Check Discharge Disposition

a. If Discharge Disposition is missing, the case will proceed to a Measure Category Assignment of X for Overall Rate (HBIPS-5a) and will be rejected. Continue processing and proceed to step 10 and Initialize the Measure Category Assignment for each strata measure.
b. If Discharge Disposition equals 6, the case will proceed to a Measure Category Assignment of B for Overall Rate (HBIPS-5a) and will not be in the measure population. Continue processing and proceed to step 10 and initialize the Measure Category Assignment for each strata measure.
c. If Discharge Disposition equals 1, 2, 3, 4, 5, 7, or 8, continue processing and proceed to check Psychiatric Care Setting.

5. Check Psychiatric Care Setting

a. If Psychiatric Care Setting equals No, the case will proceed to a Measure Category Assignment of B for Overall Rate (HBIPS-5a) and will not be in the measure population. Continue processing and proceed to step 10 and initialize the Measure Category Assignment for each strata measure.
b. If Psychiatric Care Setting is missing, the case will proceed to a Measure Category Assignment of X for Overall Rate (HBIPS-5a) and will be rejected. Continue processing and proceed to step 10 and Initialize the Measure Category Assignment for each strata measure.
c. If Psychiatric Care Setting equals Yes, the case will proceed to check Patient Status at Discharge.

6. Check Patient Status at Discharge

a. If Patient Status at Discharge is missing, the case will proceed to a Measure Category Assignment of X for Overall Rate (HBIPS-5a) and will be rejected. Continue processing and proceed to step 10 and Initialize the Measure Category Assignment for each strata measure.
b. If Patient Status at Discharge equals 2, the case will proceed to a Measure Category Assignment of B for Overall Rate (HBIPS-5a) and will not be in the measure population. Continue processing and proceed to step 10 and initialize the Measure Category Assignment for each strata measure.
c. If Patient Status at Discharge equals 1 or 3, the case will continue processing and proceed to check Number of Antipsychotic Medications Prescribed at Discharge.

7. Check Number of Antipsychotic Medications Prescribed at Discharge

a. If Number of Antipsychotic Medications Prescribed at Discharge is missing, the case will proceed to a Measure Category Assignment of X for Overall Rate (HBIPS-5a) and will be rejected. Continue processing and proceed to step 10 and Initialize the Measure Category Assignment for each strata measure.
b. If Number of Antipsychotic Medications Prescribed at Discharge is less than or equal to 1, the case will proceed to a Measure Category Assignment of B for Overall Rate (HBIPS-5a) and will not be in the measure population. Continue processing and proceed to step 10 and initialize the Measure Category Assignment for each strata measure.
c. If Number of Antipsychotic Medications Prescribed at Discharge is greater than or equal to 2 or UTD, the case will continue processing and proceed to check Number of Antipsychotic Medications Prescribed at Discharge.

8. Check Number of Antipsychotic Medications Prescribed at Discharge

a. If Number of Antipsychotic Medications Prescribed at Discharge equals UTD, the case will proceed to a Measure Category Assignment of D for Overall Rate (HBIPS-5a) and will be in the measure population. Continue processing and proceed to step 10 and initialize the Measure Category Assignment for each strata measure.
b. If Number of Antipsychotic Medications Prescribed at Discharge is greater than or equal to 2, the case will proceed to check Appropriate Justification for Multiple Antipsychotic Medications.

9. Check Appropriate Justification for Multiple Antipsychotic Medications

a. If Appropriate Justification for Multiple Antipsychotic Medications is missing, the case will proceed to a Measure Category Assignment of X for Overall Rate (HBIPS-5a) and will be rejected. Continue processing and proceed to step 10 and Initialize the Measure Category Assignment for each strata measure.
b. If Appropriate Justification for Multiple Antipsychotic Medications equals 4 or 5, the case will proceed to a Measure Category Assignment of D for Overall Rate (HBIPS-5a) and will be in the measure population. Continue processing and proceed to step 10 and initialize the Measure Category Assignment for each strata measure.
c. If Appropriate Justification for Multiple Antipsychotic Medications equals 1, 2 or 3, the case will proceed to a Measure Category Assignment of E for Overall Rate (HBIPS-5a) and will be in the numerator population. Continue processing and proceed to step 10 and initialize the Measure Category Assignment for each strata measure.

10. Initialize the Measure Category Assignment for each strata measure (b-e) = 'B'. Do not change the Measure Category Assignment that was already calculated for the overall rate (HBIPS-5a). The rest of the algorithm will reset the appropriate Measure Category Assignment to be equal to the overall rate's (HBIPS-5a) Measure Category Assignment.

11. Check Overall Rate Category Assignment

a. If Overall Rate Category Assignment equals B, Set the Measure Category Assignment for the strata measures (HBIPS-5b through HBIPS-5e) = 'B'. Stop processing.
b. If Overall Rate Category Assignment equals D or E or X, continue processing and proceed to check Patient Age at Discharge.

12. Check Patient Age at Discharge

a. If Patient Age at Discharge is greater than or equal to 1 and less than 13 years, set the Measure Category Assignment for measure HBIPS-5b equal to Measure Category Assignment for measure HBIPS-5a. Stop processing.
b. If is greater than or equal to 13 years, continue processing and proceed to check Patient Age at Discharge.

13. Check Patient Age at Discharge

a. If Patient Age at Discharge is greater than or equal to 13 and less than 18 years, set the Measure Category Assignment for measure HBIPS-5c equal to Measure Category Assignment for measure HBIPS-5a. Stop processing.
b. If Patient Age at Discharge is greater than or equal to 18 years, continue processing and proceed to check Patient Age at Discharge.

14. Check Patient Age at Discharge

a. If Patient Age at Discharge is greater than or equal to 18 and less than 65 years, set the Measure Category Assignment for measure HBIPS-5d equal to Measure Category Assignment for measure HBIPS-5a. Stop processing.
b. If Patient Age at Discharge is greater than or equal to 65 years, set the Measure Category Assignment for measure HBIPS-5e equal to Measure Category Assignment for measure HBIPS-5a. Stop processing.

Measure Information Form HBIPS-5
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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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