Hospital Based Inpatient Psychiatric Services (HBIPS)

Set Measures

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-4	Patients discharged on multiple antipsychotic medications
HBIPS-5	Patients discharged on multiple antipsychotic medications with appropriate justification
HBIPS-6	Post discharge continuing care plan created
HBIPS-7	Post discharge continuing care plan transmitted to next level of care provider upon discharge

General Data Elements

Element Name	Collected For
Admission Date	All Records,
Birthdate	All Records,
Discharge Date	All Records, Not collected for HBIPS-2 and HBIPS-3
Discharge Status	All Records, Not collected for HBIPS-2 and HBIPS-3; Used in algorithm for PC-04 and PC-05
Event Date	All Records, Not collected for HBIPS-1, 4, 5, 6 and 7
Event Type	All Records, Not collected for HBIPS-1, 4, 5, 6 and 7
ICD-9-CM Other Diagnosis Codes	All Records, Optional for HBIPS-2 and HBIPS-3; Used in algorithm for PC-01, 02, 04, and 05
ICD-9-CM Other Procedure Codes	All Records, Optional for All HBIPS Records; Used in algorithm for PC-01, 02, 04 and 05
ICD-9-CM Other Procedure Dates	All Records, Optional for All HBIPS Records
ICD-9-CM Principal Diagnosis Code	All Records, Optional for HBIPS-2 and HBIPS-3; Used in algorithm for PC-01, 02, 04, and 05
ICD-9-CM Principal Procedure Code	All Records, Optional for All HBIPS Records; Used in algorithm for PC-01, 02, 04 and 05
ICD-9-CM Principal Procedure Date	All Records, Optional for All HBIPS Records
Payment Source	All Records, Optional for HBIPS-2 and HBIPS-3
Point of Origin for Admission or Visit	All Records, Optional for HBIPS-2, HBIPS-3; Used in algorithm for PC-04, PC-05
Psychiatric Care Setting	All Records,
Sex	All Records,

Algorithm Output Data Elements

Element Name	Collected For
Measure Category Assignment	Calculation, Transmission, Hospital Clinical Data File
Measurement Value	Calculation, Transmission, Hospital Clinical Data File

Measure Set Specific Data Elements

Element Name	Collected For
Appropriate Justification for Multiple Antipsychotic Medications	HBIPS-5,
Continuing Care Plan-Discharge Medications	HBIPS-6, HBIPS-7,
Continuing Care Plan-Next Level of Care	HBIPS-6, HBIPS-7,
Continuing Care Plan-Principal Discharge Diagnosis	HBIPS-6, HBIPS-7,
Continuing Care Plan-Reason for Hospitalization	HBIPS-6, HBIPS-7,
Minutes of Physical Restraint	HBIPS-2,
Minutes of Seclusion	HBIPS-3,
Number of Antipsychotic Medications Prescribed at Discharge	HBIPS-4, HBIPS-5,
Patient Referral to Next Level of Care Provider	HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7,
Patient Strengths	HBIPS-1,
Psychiatric Inpatient Days - Medicare Only	HBIPS-2, HBIPS-3,
Psychiatric Inpatient Days-Non-Medicare Only	HBIPS-2, HBIPS-3,
Psychological Trauma History	HBIPS-1,
Substance Use	HBIPS-1,
Total Leave Days - Medicare Only	HBIPS-2, HBIPS-3,
Total Leave Days-Non-Medicare Only	HBIPS-2, HBIPS-3,
Violence Risk to Others	HBIPS-1,
Violence Risk to Self	HBIPS-1,

---

Related Materials

	Document Name
	a. Cover page for the Joint Commission Manual
	a. Table of Contents
	a1. Acknowledgment and Conditions of Use
	a1. Introduction to the Manual
	a3. Using the The Joint Commission's National Measure Specifications Manual
	b. Data Dictionary
	d. Missing and Invalid Data
	e. Sampling
	g1. Transmission of Data
	g2. Transmission Alpha Data Dictionary
	g3. Transmission Data Processing Flow: Clinical
	g4. Transmission Data Processing Flow: Population and Sampling
	z. Appendix A - ICD-9-CM Code Tables
	z. Appendix B - Medication Tables
	z. Appendix C - Glossary of Terms
	z. Appendix D - Overview of Measure Information Form and Flowchart Formats
	z. Appendix E - Miscellaneous Tables
	z. Appendix F - Resources

---

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-1, HBIPS-4, HBIPS-5, HBIPS-6, and HBIPS-7) and the other for event measures (HBIPS-2 and HBIPS-3).

Initial Patient Population for Discharge Measures (HBIPS-1, HBIPS-4, HBIPS-5, HBIPS-6, and HBIPS-7)
The population of the HBIPS discharge measures can be identified by using three data elements that are common to the discharge performance measures in the HBIPS set:

• ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes
• Discharge Date-HBIPS
• Birthdate-HBIPS

The HBIPS Discharge Topic Population is defined as patients discharged from the hospital with an ICD-9-CM Principal or Other Diagnosis Code for Psychiatric Services as defined in Appendix A, Table 10.1 and a Patient Age at Discharge (Discharge Date-HBIPS – Birthdate-HBIPS) >= 1 year. There are four distinct strata or sub-populations within the HBIPS Discharge Topic Population, each 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, 4a, 5a, 6a, and 7a (overall measures)	Age greater than and equal to 1 year	The count of all patients in strata 1, 2, 3, and 4
HBIPS-1b, 4b, 5b, 6b, and 7b	Age 1 year through 12 years	The count of all patients in stratum 1
HBIPS-1c, 4c, 5c, 6c, and 7c	Age 13 years through 17 years	The count of all patients in stratum 2
HBIPS-1d, 4d, 5d, 6d, and 7d	Age 18 years through 64 years	The count of all patients in stratum 3
HBIPS-1e, 4e, 5e, 6e, and 7e	Age greater than and equal to 65 years	The count of all patients in stratum 4

Patients discharged from the hospital with an ICD-9-CM Principal or Other Diagnosis Code for Psychiatric Services as defined in Appendix A, Table 10.1 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-HBIPS – Birthdate-HBIPS) >= 1 year and < 13 years

Discharge Stratum 2 - Age 13 years through 17 years stratum – A Patient Age at Discharge (Discharge Date-HBIPS – Birthdate-HBIPS) >= 13 years and < 18 years

Discharge Stratum 3 - Age 18 years through 64 years stratum – A Patient Age at Discharge (Discharge Date-HBIPS – Birthdate-HBIPS) >= 18 years and < 65 years

Discharge Stratum 4 - Age greater than and equal to 65 years stratum – A Patient Age at Discharge (Discharge Date-HBIPS – Birthdate-HBIPS) >= 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-HBIPS) >= 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-HBIPS) >= 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-HBIPS) >= 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-HBIPS) >= 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-HBIPS) >= 65 years

---

---

Sample Size Requirements

Sample Size Requirements for HBIPS Discharge Measures (HBIPS-1, HBIPS-4, HBIPS-5, HBIPS-6, and HBIPS-7)
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 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 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-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.

• 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 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 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 Size Requirements for HBIPS Event Measures (HBIPS-2 and HBIPS-3)
The measures HBIPS-2 and HBIPS-3 are not eligible for sampling and will use the entire Initial Patient Population for reporting.