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|
|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)|
Specification Resources for IPFQR Program Measures
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.
|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 B||Screening for Metabolic Disorders Measure|
Beginning with the FY 2017 payment determination and subsequent years, CMS requires non-measure data as an aggregate, yearly count. It is vital for IPFs to accurately determine and submit general population data for CMS to assess data reporting completeness for their total population, both Medicare and non-Medicare. In addition to providing the total, annual discharge volume, IPFs are to provide these data by payer category (Medicare and non-Medicare), age group, and diagnostic category.
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.
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.