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Performance Measurement and Quality Improvement

Inpatient performance measures focus on persons receiving services from hospitals, institutions, and residential programs. NRI was a collaborating organization with the National Association of Psychiatric Health Systems (NAPHS), the American Psychiatric Association (APA), and the National Association of State Mental Health Program Directors (NASMHPD) to engage The Joint Commission to begin development of a core measure set for psychiatric hospitals.

The result of this effort was the Hospital Based Inpatient Psychiatric Services (HBIPS) core measure set, administered by The Joint Commission, and the first measure set required from all free-standing psychiatric facilities meeting The Joint Commission’s hospital accreditation program. NRI supports the HBIPS measures through its Behavioral Healthcare Performance Measurement System (BHPMS).

Three of the 7 HBIPS measures are required inpatient performance measures for the Inpatient Psychiatric Facility Quality Reporting (IPFQR) program of the Centers for Medicare and Medicaid Services (CMS), affecting more than 1,500 psychiatric hospitals and psychiatric units. An alcohol use screening measure and tobacco screening and treatment measures (administered by The Joint Commission), and a follow-up after hospitalization measure and patients’ influenza vaccination measure, (both adapted from the National Committee for Quality Assurance), have been added to the IPFQR program list of required quality metrics. CMS will continue to evaluate and add measures each year.

In addition to measures required by accreditors and funders, NRI has several other standardized performance measures in use by inpatient psychiatric facilities. Read more about the Behavioral Healthcare Performance Measurement System (BHPMS).

Individual-level inpatient measures developed and tested include, but are not limited to, improved functioning and patient experience of care. Organizational-level inpatient measures developed and tested include, but are not limited to, patient injury rates, medication error rates, and readmission rates.

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