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pdfInpatient Psychiatric Facility Quality Reporting (IPFQR) Program
HBIPS Structural Measures Data Collection Tool
Provider Name _________________________________________CCN____________________
Address __________________________________________ Telephone ___________________
Submitter Name____________________________________ Date Submitted_______________
Calendar year___________
A structural measure reflects the environment in which providers care for patients. Structural
measures assess characteristics linked to the capacity of the provider to deliver quality
healthcare. CMS believes requesting structural measures information will encourage facilities to
increase the use of tools, ultimately improving the quality of care provided to Medicare
beneficiaries.
For Inpatient Psychiatric Facility Quality Reporting participating providers, responses for all age
groups for the measures’ questions are required in order to fulfill the Annual Payment Update
(APU) requirement. If you have no data for any of the fields, please enter zero. Do not leave any
fields blank.
Please follow the Joint Commission Specifications Manual for guidance on measures data
collection, exclusions and population sampling.
Send completed forms to the Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Support Contractor:
•
•
•
via My QualityNet to the Global Exchange Group “Inpatient Psych QR Support Contractor”;
via secure FAX to Jane Tehel, Program Manager Telligen IPFQR Support (515)-558-5073, or
via mail to:
Telligen IPFQR Support
1776 West Lakes Parkway
West Des Moines, IA 50266
Attn. Jane Tehel, Program Manager
DO NOT SEND THE COMPLETED FORM VIA EMAIL.
HBIPS-2 Hours of Physical Restraint Use
NUMERATOR
Please enter the total number of hours that all psychiatric
1-12 years old
patients were in physical restraints for each age group.
13-17 years old
Q4 2012
Q1 2013
Q4 2012
Q1 2013
Q4 2012
Q1 2013
18-64 years old
65 and over
DENOMINATOR
Please enter the number of inpatient psychiatric days
1-12 years old
for each age group.
13-17 years old
(convert days to hours)
18-64 years old
65 and over
NOTE: Denominator basis is per 1,000 hours.
Measure rates of physical restraint use per inpatient
1-12 years old
psychiatric day for each age group.
13-17 years old
18-64 years old
65 and over
Overall
HBIPS-3 Hours of Seclusion Use
NUMERATOR
Please enter the total number of hours that all psychiatric
1-12 years old
patients were in seclusion for each age group.
13-17 years old
Q4 2012
Q1 2013
Q4 2012
Q1 2013
Q4 2012
Q1 2013
18-64 years old
65 and over
DENOMINATOR
Please enter the number of inpatient psychiatric days
1-12 years old
for each age group.
13-17 years old
18-64 years old
65 and over
Measure rates of seclusion use per inpatient psychiatric day
1-12 years old
for each age group.
13-17 years old
18-64 years old
65 and over
Overall
HBIPS-4 Patients Discharged on Multiple Antipsychotic Medications
NUMERATOR
Please enter the number of psychiatric patients discharged
1-12 years old
on multiple antipsychotic medications for each age group.
13-17 years old
Q4 2012
Q1 2013
Q4 2012
Q1 2013
Q4 2012
Q1 2013
18-64 years old
65 and over
DENOMINATOR
Please enter the total number of psychiatric patients
1-12 years old
discharged for each age group.
13-17 years old
18-64 years old
65 and over
Measure rates of psychiatric patients who were discharged
1-12 years old
on multiple antipsychotic medications for each age group.
13-17 years old
18-64 years old
65 and over
Overall
HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate
Justification
NUMERATOR
Please enter the number of psychiatric patients discharged
1-12 years old
on two or more multiple antipsychotic medications
13-17 years old
for each age group.
18-64 years old
Q4 2012
Q1 2013
Q4 2012
Q1 2013
Q4 2012
Q1 2013
65 and over
DENOMINATOR
Please enter the total number of psychiatric patients
1-12 years old
discharged for each age group.
13-17 years old
18-64 years old
65 and over
Measure rates of psychiatric patients who were discharged
1-12 years old
on multiple antipsychotic medications with appropriate
13-17 years old
justification for each age group.
18-64 years old
65 and over
Overall
HBIPS-6 Patients Discharged from a Hospital-based Inpatient Psychiatric Setting with a
Continuing Care Plan Created
NUMERATOR
Please enter the number of psychiatric patients for whom
1-12 years old
the post discharge continuing care plan is created and contains
13-17 years old
all of the following: reason for hospitalization, principal
18-64 years old
discharge diagnosis, discharge medications, and next level of
65 and over
Q4 2012
Q1 2013
Q4 2012
Q1 2013
Q4 2012
Q1 2013
care.
DENOMINATOR
Please enter the total number of psychiatric patients
1-12 years old
discharged for each age group.
13-17 years old
18-64 years old
65 and over
Measure rates of psychiatric patients who were discharged
1-12 years old
from a hospital-based inpatient psychiatric setting
13-17 years old
with a Continuing Care Plan Created for each age group.
18-64 years old
65 and over
Overall
HBIPS-7 Patients Discharged from a Hospital-based Inpatient Psychiatric Setting with a
Continuing Care Plan Provided to the Next Level of Care Clinician or Entity.
NUMERATOR
Please enter the number of psychiatric patients for whom
1-12 years old
the post discharge continuing care plan was transmitted
13-17 years old
to the next level of care.
18-64 years old
Q4 2012
Q1 2013
Q4 2012
Q1 2013
Q4 2012
Q1 2013
65 and over
DENOMINATOR
Please enter the total number of psychiatric patients
1-12 years old
discharged for each age group.
13-17 years old
18-64 years old
65 and over
Measure rate of psychiatric patients who were discharged
1-12 years old
from a hospital-based inpatient psychiatric setting
13-17 years old
with a continuing care plan provided to the next level of care
18-64 years old
for each age group.
65 and over
Overall
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1171 . The time required to complete this
information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
| File Type | application/pdf |
| File Title | CMS IPF Data Collection Paper Form Final |
| Subject | CMS IPF Data Collection Paper Form Final |
| Author | CMS |
| File Modified | 2013-05-13 |
| File Created | 2013-05-13 |