Measure Information Form

Measure Set: Hospital Based Inpatient Psychiatric Services (HBIPS)

Set Measure ID: HBIPS-3

Set Measure ID	Performance Measure Name
HBIPS-3a	Seclusion- Overall Rate
HBIPS-3b	Seclusion- Children (1 through 12 years)
HBIPS-3c	Seclusion- Adolescent (13 through 17 years)
HBIPS-3d	Seclusion- Adult (18 through 64 years)
HBIPS-3e	Seclusion- Older Adult (≥ 65 years)

Performance Measure Name: Hours of seclusion use

Description: The total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were held in seclusion.

Rationale: The use of seclusion is increasingly viewed as an intervention of last resort and reducing the use of seclusion can align inpatient psychiatric care that values and respects patients’ rights and autonomy (Konnyu et al., 2023). The use of seclusion and restraint is limited to situations deemed to meet the threshold of imminent danger and when restraint and seclusion are used; such use is rigorously monitored and analyzed to prevent future use. In preventing escalations of violence or aggression, providers should employ a comprehensive initial and ongoing assessment including assessing risk for aggression using a standardized tool, ensuring active patient participation in developing treatment plans and including interventions that have been successful in preventing escalation in the past (American Psychiatric Nurses Association [APNA], 2022).

Seclusion or restraint should be initiated only when less restrictive measures have proven ineffective, and the behavioral emergency poses serious and imminent danger to the person, staff, or others. Such interventions should be discontinued as soon as the behavioral criteria for release has been met, and never used as punishment (APNA, 2022).

Providers should first attempt verbal de-escalation, and establish clear protocols to guide decision-making for the initiation and removal of restraint and seclusion (American Psychiatric Association, 2022).

Type Of Measure: Process

Improvement Noted As: Decrease in the rate

Numerator Statement: The total number of hours that all psychiatric inpatients were held in seclusion

Numerator Basis: The numerator evaluates the number of hours of seclusion; however, the algorithm calculates the number of minutes to ensure a more accurate calculation of the measure. Convert the minutes to hours when analyzing and reporting this measure.

Refer to the HBIPS-2 and HBIPS-3 data element calculation example in the data entry guide for technical guidance.

Included Populations:

Patients for whom at least one seclusion event is reported during the month

Excluded Populations: None
Data Elements:

Event Date

Event Type

Minutes of Seclusion

Denominator Statement: Number of psychiatric inpatient days

Denominator Basis: per 1,000 hours

Refer to the HBIPS-2 and HBIPS-3 data element calculation example in the data entry guide for technical guidance for aggregated denominator.

Included Populations:

All psychiatric inpatient days

Excluded Populations:

Total leave days

Data Elements:

Admission Date

Birthdate

Psychiatric Care Setting

Psychiatric Inpatient Days-Non-Medicare Only

Psychiatric Inpatient Days - Medicare Only

Total Leave Days-Non-Medicare Only

Total Leave Days - Medicare Only

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: In order to further examine the issue of seclusion use within your facility it may be useful to study the incidence of seclusion use by collecting additional information about the clinical justification for use.

Sampling: No.

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

Selected References:

American Psychiatric Association. (2022). APA resource document: Seclusion and restraint. https://www.psychiatry.org/getattachment/e9b21b26-c933-4794-a3c4-01ad427eed91/Resource-Document-Seclusion-Restraint.pdf
American Psychiatric Nurses Association. (2022). APNA standards of practice: Seclusion and restraint. https://www.apna.org/standards-of-practice-seclusion-and-restraint/
Konnyu, K., Quinn, M. K., Primack, J., Balk, E., Trikalinos, T. A., Rudolph, J. L., & Jutkowitz, E. (2023). Protocols to reduce seclusion in inpatient mental health units: A systematic review. Department of Veterans Affairs, Evidence Synthesis Program. https://www.ncbi.nlm.nih.gov/books/NBK599803

Measure Algorithm:
Graphic depiction of the Measure Algorithm. Refer to the Algorithm Narrative for each detailed step.

HBIPS-3: Hours of Seclusion Use

Algorithm Narrative
Numerator Statement: The total number of hours that all psychiatric inpatients were held in seclusion
Denominator Statement: Number of psychiatric inpatient days

Variable Key: Patient Age at Time of Event

Stratified Measure Name:
HBIPS-3a Overall Rate
HBIPS-3b Children1-12 years
HBIPS-3c Adolescent 13-17 years
HBIPS-3d Adult 18-64 years
HBIPS-3e Older Adult >=65 years

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

2. Check Event Type

a. If Event Type equals 1, the case will proceed to a Measure Category Assignment of U for Overall Rate (HBIPS-3a) and will not be in the numerator population. Continue processing and proceed to step 4, to check Overall Rate Category Assignment.
b. If Event Type equals 2, continue processing and proceed to check Minutes of Seclusion.

3. Check Minutes of Seclusion

a. If Minutes of Seclusion is missing, the case will proceed to a Measure Category Assignment of X for Overall Rate (HBIPS-3a) and will be rejected. Continue processing and proceed to step 4, to check Overall Rate Category Assignment.
b. If Minutes of Seclusion equals UTD, the case will proceed to a Measure Category Assignment of Y for Overall Rate (HBIPS-3a) and will be in the measure population. Continue processing and proceed to step 4, to check Overall Rate Category Assignment.
c. If Minutes of Seclusion equals a Non-UTD value, the case will proceed to a Measure Category Assignment of E for Overall Rate (HBIPS-3a) and will be in the numerator population. Continue processing and proceed to step 4, to check Overall Rate Category Assignment.

4. Check Overall Rate Category Assignment

a. If Overall Rate Category Assignment equals U, Set the Measure Category Assignment for the strata measures (b-e) = 'U'. Stop processing.
b. If Overall Rate Category Assignment equals E, X, or Y, continue processing and initialize the Measure Category Assignment for each strata measure (b-e) = ‘B’. Do not change the Measure Category Assignment or Total Overall Seclusion Minutes that was already calculated for the overall rate (HBIPS-3a).

5. Check Patient Age at Time of Event

a. If Patient Age at Time of Event is greater than or equal to 1 and less than 13 years, set the Measure Category Assignment for measure HBIPS-3b equal to Measure Category Assignment for measure HBIPS-3a. Stop processing.
b. If Patient Age at Time of Event is greater than or equal to 13 years, continue processing and proceed to check Patient Age at Time of Event.
c. If Patient Age at Time of Event is greater than or equal to 13 and less than 18 years, set the Measure Category Assignment for measure HBIPS-3c equal to Measure Category Assignment for measure HBIPS-3a. Stop processing.
d. 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.
e. If Patient Age at Time of Event is greater than or equal to 18 and less than 65 years, set the Measure Category Assignment for measure HBIPS-3d equal to Measure Category Assignment for measure HBIPS-3a. Stop processing.
f. If Patient Age at Time of Event is greater than or equal to 65 years, set the Measure Category Assignment for measure HBIPS-3e equal to Measure Category Assignment for measure HBIPS-3a. Stop processing.

Specifications Manual for Joint Commission National Quality Measures (v2027A)
Discharges 01-01-2027 (1Q27) through 06-30-2027 (2Q27)

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