Measures

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program

The following list of Clinical Quality Measures is identified by CMS for collection for the Inpatient Psychiatric Facility Quality Reporting (IPFQR) program beginning October 1, 2012. The primary purpose of these measures is to promote high quality of care for patients receiving services in psychiatric facilities and distinct units.

Fiscal Year 2020 and Subsequent Years

Measure ID Measure Description
HBIPS-2 Hours of Physical Restraint Use
HBIPS-3 Hours of Seclusion Use
HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification
N/A Transition Record with Specified Elements Received by Discharged Patients
N/A Timely Transmission of Transition Record
N/A Screening for Metabolic Disorders
SUB-2 and SUB-2a Alcohol Use Brief Intervention Provided or Offered and the subset, Alcohol Use Brief Intervention
SUB-3 and SUB-3a Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge and the subset, Alcohol and Other Drug Use Disorder Treatment at Discharge
TOB-2 and TOB-2a Tobacco Use Treatment Provided or Offered and the subset, Tobacco Use Treatment (during the hospital stay)
TOB-3 and TOB-3a Tobacco Use Treatment Provided or Offered at Discharge and the subset, Tobacco Use Treatment at Discharge
IMM-2 Influenza Immunization
FUH Follow-Up After Hospitalization for Mental Illness
N/A 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an Inpatient Psychiatric Facility (IPF)

The IPFQR Program measures were developed and are maintained by various measure stewards, as indicated in the table below. This and other measure-related information can be found in Section 2: Measure Details of the IPFQR Program Manual, which is located on the IPF Resources page.

Specification Resources for IPFQR Program Measures

Specifications Resource as
Defined by the Measure Steward
IPFQR Program Measures
Specifications Manual for National Hospital Inpatient Quality Measures Tobacco Treatment (TOB), Substance Use (SUB), and Influenza Immunization
(IMM-2) measure sets
Specifications Manual for Joint Commission National Quality Measures HBIPS-2, -3, -5
Care Transitions - Performance
Measurement Set
(American Medical Association [AMA]-convened Physician Consortium for Performance Improvement® [PCPI])
Transition Record with Specified Elements Received by Discharged Patients and Timely Transmission of Transition Record
IPFQR Program Claims-Based Measure Specifications Follow-Up After Hospitalization (FUH) for Mental Illness and 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an IPF
IPFQR Program Manual - Appendix D Screening for Metabolic Disorders Measure

Data collection

CMS collects annual, aggregate measure and non-measure data for the IPFQR Program as described in Section 2: Measure Details of the IPFQR Program Manual, which is located on the IPF Resources page.

Data submission

Participating facilities are required to submit their aggregate data for the required measures and acknowledge that all information submitted for the Inpatient Psychiatric Facility Quality Reporting Program is complete and accurate to the best of their knowledge at the time of submission. The measure data, non-measure data, and Data Accuracy and Completeness Acknowledgement (DACA) are submitted via the secure online CMS Web-based tool accessible through the QualityNet Secure Portal annually during the reporting period.

Data Accuracy and Completeness Acknowledgement (DACA)

Following the submission of the data, facilities acknowledge all the information that it submitted as required by the IPFQR program is complete and accurate to the best of its knowledge by the submission deadline of August 15, prior to the respective payment determination year.

Use of Vendors

A third-party vendor may submit data on a participant’s behalf if previously authorized by the facility. The facility must complete the online authorization process accessible from the QualityNet Secure Portal. However, the facility is responsible for the data and the submission of the DACA.

Archived IPF Readmission Measure Dry Run Information, PDF

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