Kenneth Duckworth, MD, medical director at Vinfen Corporation in Boston, recalls the frustration he felt when inpatient hospital staff would release his psychiatric patients without contacting him. The lack of communication often led to gaps in his patients’ records and left him scrambling to learn more about the circumstances of the hospitalization.
Those experiences are among the reasons Dr. Duckworth, a triple-board-certified psychiatrist and medical director of the National Alliance on Mental Illness (NAMI), was pleased to hear The Joint Commission had released its Hospital-Based Inpatient Psychiatric Services, or HBIPS, measure set. And he’s not alone. HBIPS provides standardized measures for psychiatric services where previously none existed, and it gives hospitals the ability to use their data as a basis for national comparison.
Ann Watt, associate director, division of quality measurement and research at the Joint Commission, says although it’s still early, the measures seem to be working. “While we don’t have any actual data, we have received positive feedback,” she says. “It seems like the field has accepted them well.”
Standard of Care Guidelines
Comprised of seven main measures that the commission released in October 2008, HBIPS is the result of a determined effort by the nation’s psychiatry leaders, says Noel Mazade, PhD, executive director of the National Association of State Mental Health Program Directors’ Research Institute Inc. HBIPS is available to hospitals accredited under the Comprehensive Accreditation Manual for Hospitals (CAMH), says Celeste Milton, associate project director at the commission’s Department of Quality Measurement. Free-standing psychiatric hospitals and acute-care hospitals with psychiatric units can use the HBIPS measure set to help meet performance requirements under the commission’s ORYX initiative (www. jointcommission.org/AccreditationPrograms/Hospitals/ORYX/).
The Joint Commission’s final HBIPS measure set, which went into effect with Oct. 1, 2008, discharges, followed more than three years’ of field review, public comment, and pilot testing by 196 hospitals across the country. HBIPS’ seven measures address:
—Tim Lineberry, MD, medical director, Mayo Clinic Psychiatric Hospital, Rochester, Minn.
- Admission screening;
- Hours of physical restraint;
- Hours of seclusion;
- Patients discharged on multiple antipsychotic medications;
- Patients discharged on multiple antipsychotic medications with appropriate justification;
- Post-discharge plan creation; and
- Post-discharge plans transmitted to the next level of care provider.
“These are all areas that are of interest to NAMI,” Dr. Duckworth says. “We still have a long way to go, but it’s definitely a step in the right direction.”
The measure set’s effect on psychiatric hospitalists will depend on physicians’ responsibilities at the facilities where they work, Milton says. For example, a psychiatric hospitalist may be asked to screen a patient at admission for violence risk, substance abuse, psychological trauma history, and strengths, such as personal motivation and family involvement (HBIPS Measure 1). Another qualified psychiatric practitioner, such as a psychiatrist, registered nurse, physician’s assistant, or social worker, could perform the screening, she says.
The measures are intended to help unify the screening process used by psychiatric hospitalists; however, traditional hospitalists could be called on to perform a face-to-face evaluation of a patient placed in physical restraint or held in seclusion (Measures 2 and 3). As a result of the evaluation, hospitalists could be asked to write orders to discontinue or renew physical restraint or seclusion, Milton says. The feedback the Joint Commission has received shows psychiatric hospitalists are using the measures. They are most likely to be in charge of managing a patient’s medications and could play a role in documenting appropriate justification for placing a patient on more than one antipsychotic medication at discharge (Measures 4 and 5). Depending on the scope of practice, traditional hospitalists who discharge patients might be responsible for determining a final discharge diagnosis, discharge medications, and next-level-of-care recommendations (Measures 6 and 7). The provider at the next level of care could be an inpatient or outpatient clinician or entity, Milton says.
How It Works
The HBIPS data collection process is similar to other ORYX processes; however, this is the first time the Joint Commission has created a measure set for psychiatric services, says Dr. Mazade, who worked directly with the commission to develop HBIPS. Hospitals using HBIPS will submit data from patients’ medical records to their ORYX vendor. The vendor will submit performance measures to the hospital and the commission, which will provide hospitals with feedback on measure performance, Dr. Mazade says. Initially, the commission will supply acute-care and psychiatric hospitals the option of using HBIPS to meet current ORYX performance measurement requirements, although Dr. Mazade says he expects the commission will eventually mandate use of the measures.
The commission says data collection, analysis, and performance reporting is running behind schedule. Once the commission report is received, hospitals should share the message with their medical staff, Milton says. “This feedback will be useful to all staff involved in patient care to help them improve their practice,” she explains. “The purpose of an initial screening, including a trauma history, is to help the practitioner formulate an individual treatment plan based on information obtained during the initial screening.”
Tim Lineberry, MD, medical director at the Mayo Clinic Psychiatric Hospital in Rochester, Minn., says each HBIPS measure is composed of sub-elements. For example, the assessment measure includes admission screening for violence risk, substance abuse, trauma history, and patient strengths, such as motivation and family involvement. These elements create a more complete picture of the patient and might improve the initial assessment. By improving initial assessment, experts in the field hope hospital staff will be able to better identify problems, Dr. Lineberry says.
“We are all working for improvement in care,” says Dr. Lineberry, noting the Mayo Clinic was one of the pilot sites. “HBIPS is part of that effort.”
Time Is of the Essence
Many of the standards represent areas in which there is consensus among psychiatrists about the need for change, says Anand Pandya, MD, a psychiatric hospitalist and director of inpatient psychiatry at Cedars-Sinai Medical Center in Los Angeles. Many psychiatrists recognize there is a need to improve communication between inpatient psychiatric services and follow-up outpatient providers, Dr. Pandya says. However, a clear consensus has not been reached regarding the standards of tracking patients who take multiple antipsychotic medications, Dr. Pandya says.
“With the low average length of stay in inpatient psychiatric units, it is common for patients to continue a cross-taper between medications after discharge,” Dr. Pandya says. “For most antipsychotic medications, there is insufficient data to determine how fast or slow to cross-taper. I worry that these standards may send the unintentional message that these cross-tapers should be completed quickly during the course of a brief inpatient stay.”
Data suggest individuals using lithium should be tapered off the drug as slowly as possible—probably over months rather than weeks, Dr. Pandya says. “I am concerned that tracking data regarding patients on multiple antipsychotic medications may create incentives to change practice in a sub-optimal direction for some cases,” he says.
Dr. Duckworth also acknowledges patients’ length of stay is getting shorter. Psychiatric hospitalists are under a great deal of pressure to “get people patched up in too short a period of time,” he says. “They really do need more time. There is a temptation to use more than one antipsychotic medication, but people really should not be given two antipsychotic medications unless someone has performed a thoughtful assessment.”
On Board with HBIPS
While HBIPS covers areas of care important to many, the details of implementing the measure set might be challenging, Dr. Lineberry says. The requirements increase the documentation burden for physicians, nurses, and allied health professionals, such as social workers and therapists. Hospitals using electronic medical records might have to modify their records to meet the requirements. And with the new measure comes new, significant personnel costs to audit and collect the data, he says.
“For psychiatric hospitalists who are using HBIPS, it will be helpful to look at the measures from a multidisciplinary standpoint,” Dr. Lineberry says. “Approach HBIPS as a team. Look at the process and see how it works, then adapt it to fit in with your current workflow.”
As of July, more than 274 psychiatric hospitals and psychiatric units had implemented the HBIPS measures. “We don’t usually have numbers until at least six months after,” Milton says, noting the commission is eager to receive quantitative data and report back to the participating hospitals.
Milton anticipates the Joint Commission will submit the HBIPS measure set to the National Quality Forum (NQF) for consideration and endorsement. Although she anticipates the measures will receive NQF endorsement sometime this year, an exact timeline has not been established, she says. The Joint Commission will work closely with the NQF to ensure the HBIPS measure set receives endorsement, and will make necessary modifications that may be required, Milton says.
Once HBIPS receives NQF endorsement, HBIPS data will be publicly reported following the first two quarters of data collection, Milton says. Data on each hospital will be available at www.qualitycheck.org. TH
Gina Gotsill is a freelance medical writer in California. Freelance writer Chris Haliskoe contributed to this report.
Image Source: TIM TEEBKEN/PHOTODISC