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 2019 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-1||Alcohol Use Screening|
|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-1||Tobacco Use Screening|
|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|
|N/A||Influenza Vaccination Coverage Among Healthcare Personnel|
|N/A||Assessment of Patient Experience of Care|
|N/A||Use of an Electronic Health Record (EHR)|
|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|
|Healthcare Personnel Vaccination Module: Influenza Vaccination Summary Protocol
July 2017 (NHSN)
|Influenza Vaccination Among Healthcare Personnel (HCP)|
|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|
CDC and CMS Joint Reminder on NHSN Reporting
The Center for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) is the nation’s most comprehensive medical event tracking system, that is currently utilized by more than 16,000 U.S. healthcare facilities. NHSN provides critical data to guide prevention efforts aimed at protecting patients.
The CDC and the Centers for Medicare & Medicaid Services (CMS) are committed to ensuring data accuracy and reliability for guiding prevention priorities and protecting patients. Identifying infections and making sure that patients receive the highest quality of care is our top priority.
CDC and CMS want to emphasize that accurate reporting to NHSN through strict adherence to the NHSN definitions is critical to quality of care measurement and improvement. Read about NHSN reporting on the CDC website.
CMS collects annual, aggregate measure and non-measure data for the IPFQR Program as described on pages 33-36 of the IPFQR Program Manual. Refer to the IPFQR Program Manual (Section 2: Measure Details) located on the IPF Resources page for more information about data collection and associated paper tools.
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.