Hbips Tracking Sheet For Hbips-2 And Hbips-3, Ipf Quality Reporting

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Instructions for Hospi)tal-Based Inpatient Psychiatric Services (HBIPS)
Event Tracking Log for Event Measures HBIPS-2 and HBIPS-3
01-01-2017 (Q1 2017) through 12-31-2017 (Q4 2017
The Hospital-Based Inpatient Psychiatric Services (HBIPS) Event Tracking Log tool is provided
as an optional, informal mechanism to aid psychiatric facilities and hospital psychiatric units in
the collection of measure data for the Centers for Medicare & Medicaid Services (CMS)
Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program. Facilities can choose to track
events daily, weekly, monthly, or quarterly. It is suggested that facilities print two separate Event
Tracking Logs, one for HBIPS-2: Hours of Physical Restraint Use and a second for HBIPS-3:
Hours of Seclusion Use. CMS is not responsible for potential errors and issues arising from
modifications made by external parties. If there are any questions or concerns regarding the use
of this Event Tracking Log, please contact the IPFQR Program Support Contractor at
.
Measures:
HBIPS-2: Hours of Physical Restraint Use
HBIPS-3: Hours of Seclusion Use
Track each event by completing the fields in the numerator table. These measures do not allow
sampling. The steps below will provide monthly numerator and denominator values that will be
aggregated for an annual entry into the QualityNet Secure Portal.
I.
Calculate the Numerator
1. Determine the daily event minutes for each patient by entering the start and end
times in the Event Tracking Log on page three of this document.
2. Total the daily event minutes by patient.
3. Determine the total event minutes by month.
4. Divide total monthly minutes by 60 minutes to convert to hours.
5. Enter the total hours (from Step 4) into the numerator field on page three, Step A.
Monthly Numerator Calculation Example
For the month of July, the facility’s total minutes of Restraint (or Seclusion) Use = 253.
Divide the total minutes of Restraint (or Seclusion) Use by 60 minutes: 253 ÷ 60 = 4.220
hours. The total numerator for July is 4.22 hours of Restraint (or Seclusion) Use.
II. Calculate the Denominator
1. Determine the total number of Inpatient Days by month for all patients.
2. Determine the annual total of Inpatient Days.
3. Determine the total number of Leave Days (defined below) by month for all patients.
The Specifications Manual for Joint Commission National Quality Measures defines
a leave day as, “an authorized or unauthorized absence from a facility, excluding
discharges, during which the patient is absent from the facility at the time of the daily
census and is not under the direct supervision of facility staff while absent.”
4. Determine the annual total of Leave Days.
5. Subtract the Total Leave Days from Total Inpatient Days.
6. Enter the Total Number of Days (from Step 5) into the Denominator field on page
three of this document, Step B.
Page 1 of 3
Event Tracking Log for Event Measures HBIPS-2 and HBIPS-3
Discharges 01-01-17 (Q1 2017) through 12-31-17 (Q4 2017)

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