In a step toward standardization of quality measures for inpatient
psychiatric facilities, the Joint Commission (JC) has issued a set of five
measures that are expected to be available for adoption by freestanding
psychiatric facilities and psychiatry departments in general hospitals
beginning October 1.
The new measures, known as the Hospital-Based, Inpatient Psychiatric
Services (HBIPS) core measure set, address the following five areas of
inpatient psychiatric practice:
Celeste Milton, associate project director for the HBIPS, told
Psychiatric News that the HBIPS measures have been posted on the JC
Web site to give time for vendors—the commercial and other organizations
that provide hospitals with the infrastructure for quality
measurement—to develop programs targeted toward the measures.
Facilities may begin to incorporate the measures on October 1 or continue
to use the "noncore" measures already available from the JC. (The
noncore measures became effective for all discharges from general hospitals at
the beginning of the year, but have been voluntary for psychiatric facilities;
they too can be accessed online at the JC Web site.)
However, the new HBIPS measures must be approved by the National Quality
Forum before they are considered mandatory. That process is under way, but"
it is highly unlikely that the measures will be required by January 1
as an endorsed set," Milton said.
Also, facilities' performance on the measures are not required to be made
public, but they will be used by the JC for accreditation purposes.
Psychiatrists involved in the development of the guidelines said that
generally they will be an improvement because they represent a step toward
consolidating and standardizing the many quality measures being issued by
different managed care organizations, state mental health authorities, and
"When you are seeing patients, you don't treat their insurance
company, you treat patients," Richard Hermann, M.D., told
Psychiatric News. "So the heterogeneity of measures from a
clinical and inpatient management point of view is horrific. The trend over
the last five years has been consolidation and standardization across measure
"That's what is happening in inpatient care. It's a good step any
time you can increase standardization and focus on topics that are worthwhile,
decreasing the burden on clinicians with a smaller set of measures."
Hermann is director of the Center for Quality Assessment and Improvement in
Mental Health at Tufts University School of Medicine and a member of the JC
Technical Advisory Panel to Identify Core Performance Measures for HBIPS.
(Members of the advisory panel were chosen for their technical expertise and
were not representing specific organizations; however, several APA members in
addition to Hermann were on the panel.)
Hermann said t he measures are the product of a process involving the
National Association of Private Psychiatric Health Systems and the National
Association of State Mental Health Program Directors.
Beginning in January 2007, the measures were test piloted by 147 general
and stand-alone psychiatric facilities, he said.
Psychiatrist John Oldham, M.D., who is APA's representative to the
executive committee of the AMA's Physicians Consortium on Quality and a member
of the JC advisory panel, said some of the new measures may work better than
others, but that in general they should help to improve inpatient care.
"They are all fairly logical and straightforward," he told
Psychiatric News. "I think they could be helpful." He is
also a consultant to APA's Council on Quality Care.
Oldham said that with regard to the use of restraints and seclusion, the
two measures ask facilities to tally the total number of hours in which any
patient is in restraints or seclusion divided by the total inpatient
But he said many facilities have already made dramatic improvements in this
area. "The movement to reduce restraints and seclusion is well
along," he said. "It is remarkable what hospitals have been able
to accomplish [in this area] anyway."
Assessment at admission of violence risk, history of trauma or substance
abuse, and patient strengths may be more challenging. "This measure is a
complicated one that calls for documentation about several areas that may be
subject to different interpretations," he said. "More experience
with the measure may clarify its usefulness."
The problem of polypharmacy is a critical one, he said, as there is a
consensus that far too many patients are discharged on multiple antipsychotics
or other drugs. "But it's a real challenge to craft [the quality
measure] right, because there are legitimate reasons for a patient being on
more than one medication," Oldham said. The measure addressing poly
pharmacy is designed to incorporate the inevitability of exceptions, such as
when a patient is being cross-tapered from one medication to another, Oldham
But Oldham said he believes one of the most crucial areas for quality
improvement in hospital care of psychiatric patients is in the area of
follow-up and continuity of care. Thus one measure addresses the transfer of
information from the inpatient facility to whatever follow-up care the patient
is referred in the community.