Joint Commission to Issue Inpatient Quality Measures

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 other payers.

“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 developers.

“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 psychiatric days.

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 explained.

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.

The draft measures are posted<www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Hospital+Based+Inpatient+Psychiatric+Services.htm>.▪