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HBIPS core measure set ready for public display
Freestanding psychiatric hospitals must report
According to many stakeholders of the hospital-based inpatient psychiatric services (HBIPS) core measure set, it's been a long time coming. Although the set has been an option for hospitals since 2008, work on it began more than seven years ago, and now it will be mandatory for freestanding psychiatric hospitals beginning Jan. 1, 2011.
This "is the first time we're requiring the use of a particular core measure set. Because that's the only set available" specifically to psychiatric hospitals, says Frank Zibrat, associate director, ORYX implementation, division of accreditation operations at The Joint Commission.
Zibrat says reporting on the measure set is mandatory only for freestanding hospitals, which The Joint Commission defines as those that are accredited separately from the general medical/surgical hospital and have their own Joint Commission ID number. Those hospitals accredited as part of a general medical surgical hospital will not be required to report on the set, although "we would encourage it," he says.
The core measure set contains seven components:
Of those, all but the first have been endorsed by the National Quality Forum, Zibrat says. Despite that, The Joint Commission has decided to move forward with all seven components of the set and, beginning in about January 2012, will publicly display the data on the six NQF-endorsed measures. "The same thing will hold true with all those internal Joint Commission applications that use the core measure data. We will only use the six NQF-endorsed measures. And we hope that at some point in the future, that one measure will be NQF-endorsed, and when it is then we'll go ahead and include it in the public display."
Representatives from the National Association of Psychiatric Health Systems (NAPHS), the National Association of State Mental Health Program Directors (NASMHPD), the American Psychiatric Association, and the NASMHPD Research Institute Inc. (NRI Inc.), among others, were part of the national stakeholders that approached The Joint Commission and asked for the development of a core measurement set for psychiatric inpatient treatment.
"One of our purposes here was to show that what is done in the psychiatric hospital can be measured with the same kind of rigor and evidence-based approach on the medical surgical side... What we've been saying is that we want to be part of and we are really part of overall health care. Therefore, we need to show that we can measure what we do on the same basis as they do in med /surg, and we believe this is a critical step in that direction," says Mark Covall, president and CEO of NAPHS.
Because previously there was no specific measure set for psychiatric care, there weren't any national benchmarks, Covall says. "[A] lot of our members at the time were saying, 'We're collecting a lot of information but it's really not actionable, it's not really helping us change practice. We're spending a lot of money in resources, but we're not able to really make a difference or change what we're doing to help patients.'
"So that was one of the core reasons that led to this effort. Throughout the process of developing these measures, that was always something that was key. As we go forward and as we made decisions (for example, on whether we choose a measure or how we develop definitions), the issue is whether a measure is really going to help in changing practices so that people actually improve the care that's being delivered." He says with the HBIPS core measure set, the field will have common definitions, which will result in more meaningful data.
Since 2008, the measure set has gone through a number of modifications. For example, "instead of there being one measurement ratio on a couple of these measures, some are in fact being reported as two separate entities. Mostly that was to create more specificity and more opportunities for people to improve components of one of these scores," says Frank A. Ghinassi, PhD, clinical psychologist; vice president for quality and performance improvement, Western Psychiatric Institute and Clinic of UPMC Presbyterian-Shadyside; assistant professor in psychiatry, University of Pittsburgh School of Medicine; and chair of the Joint Commission technical advisory panel for the HBIPS performance measurement initiative.
Getting to zero on restraint, seclusion
Covall says the issue of restraint and seclusion "has become something that is very critical from the advocacy community standpoint because it's actually an issue of safety. The idea that you need to have less restraint and seclusion creates a much more positive outcome. The amount of restraint and seclusion that's being provided today has substantially decreased over the years, and this is a way to continue to measure that."
Ghinassi says the topic of restraint and seclusion comes "under the rubric of patient and staff safety issues and also it comes under the rubric of patient dignity and self-governance. The general consensus is that although restraint and seclusion have been a part of the history of psychiatric treatment, the present perspective of both consumers and providers of psychiatric care is that it is no longer seen as consistent with evidence-based care and treatment, and should be discontinued. We are moving more toward a patient-centric autonomy and recovery-oriented model where proactive collaboration between providers and consumers of care is the standard of practice."
Getting to zero is the ultimate goal, he says, and will involve earlier, more comprehensive discussion with patients on potential trigger situations and will involve clinicians and patients using pre-arranged behavioral plans.
With the introduction of these new HBIPS measures, he says, the various definitions used to report on restraint and seclusion have been more precisely defined in a clear "ratio measure based on hours of restraint and seclusion over total numbers of patient care hours; they have also been stratified by variables like age ranges, thus allowing hospitals to focus on differences in use according to the different age groups. The hope is it's going to give people reasonable benchmarks against which to push for improvement." (To review the specifications on this measure and the others in the set see the manual: http://manual.jointcommission.org/releases/TJC2010B/.)
Using multiple antipsychotics
While Covall says the task force members with clinical backgrounds felt very strongly about the measures regarding the use of multiple antipsychotics, it is a "controversial" issue as there are still differing opinions about it in the medical community. "But the research literature suggests that [use of multiple antipsychotics] needs to be carefully reviewed because sometimes use of more than one antipsychotic medication really may not be having a positive impact on their overall recovery," he says.
Ghinassi says psychiatry still has much to discover in its study of the science of brain functioning, genetics, and human behavior and disorders. There are, however, a number of well-designed studies "that have supported monotherapy [using one medication from a class]" in the treatment of psychotic disorders.
"The empirical evidence as it stands, and again it isn't complete nor is it all conclusive, tends to support that the best practice algorithm would be to start with one medication. Make sure that you get it to its adequate dose for an adequate amount of time, and if that doesn't reduce symptoms and improve functioning (with a minimum of side effects) then one is advised to switch to a second single medication. The technical advisory panel has recommended three such adequate trials of monotherapy before a practitioner should consider more complex regimens," he says.
Zibrat says he's received many calls from clinicians who have patients who have been on multiple antipsychotic medications for a long time and wonder how to handle it. "That's the kind of call that we seem to be getting relative to the measures that address the use of multiple antipsychotics. What do we do if the patient has been on this for a long time? Do you start taking them away? A lot of physicians are reluctant to do that." (For more information on measure 5 and documenting appropriate "justification" of the use of multiple antipsychotics visit http://manual.jointcommission.org/releases/TJC2010B/DataElem0137.html.)
Ghinassi says he is encouraged by the implementation of the set and the move toward providing quality-of-care benchmarks in psychiatric care. Ghinassi says: "Organizations that elect to use this measurement set are deciding to take on a significant amount of extra work in that they have to comb through charts, compile reports, and ensure that data are reliable and valid. But all of this measurement and reporting effort is in service to one very important end. And that is continuously improving the quality and safety of the care provided in psychiatric hospitals and respecting the autonomy and dignity of the individuals seeking treatment."
He says it represents a key move forward in the science of psychiatry and the adoption of standardized performance measurement and national benchmarking.
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