CMS-10432 HBIPS Measures Data Collection Tool

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
HBIPS Measures Data Collection Tool

Provider Name _________________________________________ CCN___________________

Address __________________________________________ Telephone ___________________

Submitter Name ____________________________________ Date Submitted_______________

Calendar year ___________

For Inpatient Psychiatric Facility Quality Reporting participating providers, responses are required for all fields. If you have no data for any of the fields, then please enter zero. Do not leave any fields blank.

Please follow the Joint Commission Specifications Manual for guidance on measure data collection, exclusions, and population sampling.

IPFs should complete the form in a fillable PDF format and submit via email to:

[email protected].

HBIPS-2 Hours of Physical Restraint Use

NUMERATOR CY 2017

Please enter the total number of hours that all psychiatric

patients were in physical restraints for each age group.

DENOMINATOR CY 2017

Please enter the number of inpatient psychiatric days

for each age group. (convert days to hours)

NOTE: Denominator basis is per 1,000 hours.

HBIPS-3 Hours of Seclusion Use

NUMERATOR CY 2017

Please enter the total number of hours that all psychiatric

patients were in seclusion for each age group.

DENOMINATOR CY 2017

Please enter the number of inpatient psychiatric days

for each age group.

HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification

NUMERATOR CY 2017

Please enter the number of psychiatric patients discharged

on two or more multiple antipsychotic medications

for each age group.

DENOMINATOR CY 2017

Please enter the total number of psychiatric patients

discharged for each age group.

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. Expiration Date: xx/xx/xxxx

Updated 02/2017 Page 4 of 4