If you work in a psychiatric hospital, you’ve likely gotten annoying emails detailing deficiencies in your medical records. These often come from the hospital compliance department (sometimes called Quality Services, Quality Improvement, or Quality Assurance), but they may also come from your medical director—who is likely responding to those same compliance emails. 

Typical deficiencies include:

• You haven’t documented that you offered a nicotine patch to a patient who has smoked for years.
• You haven’t been ordering lipid panels on each of your patients who’ve taken an antipsychotic, even those on no more than occasional use of 25 mg of quetiapine (Seroquel) for insomnia.
• You’ve been discharging patients on two antipsychotics without explaining in detail why you did so.

While such emails may seem like attempts to torture you, they are simply responses to laws and regulations that every psychiatric hospital is forced to follow if they want to keep the doors open and the insurance reimbursements flowing. 

Here’s a primer on quality and reporting requirements in psychiatric hospitals, including a recent update that will take some of the pressure off you and your colleagues. 

CMS and the IPFQR program

CMS refers to the Centers for Medicare & Medicaid Services, which is the government agency in charge of setting policies for how both Medicare and Medicaid pay hospitals and medical providers. In addition to reimbursing for services, CMS wants to make sure that you’re providing high-quality care to your patients, which is why it has created the Inpatient Psychiatric Facility Quality Reporting (IPFQR) program. 

The IPFQR program was initiated in 2012 as a direct outcome of the Patient Protection and Affordable Care Act, which aimed to improve the accountability and quality of care in inpatient psychiatric facilities (Shields MC and Busch AB, Med Care 2020;58(10):889–894). The program established quality measures for psychiatric hospitals across the US, including:

• Minimizing the use of physical restraints and seclusion to ensure patient safety and dignity
• Screening for and addressing patient substance use to provide comprehensive care that includes attention to substance use disorders
• Creating postdischarge continuing care plans so patients will have clear, structured plans for ongoing ­treatment

Facilities that meet the program’s requirements receive CMS’ full annual payment update (APU) for Medicare reimbursement, while those that do not comply get penalized with a 2% reduction to their APU. Although this might not sound like a lot, it can add up to millions of dollars of revenue. This financial incentive motivates hospitals to not only gather but also monitor and improve on measures related to patient care and safety.

HBIPS 

The Hospital-Based Inpatient Psychiatric Services (HBIPS) metrics consist of additional measures that the Joint Commission has compiled for psychiatric hospitals, several of which overlap with the IPFQR standards. Why have two sets of measures? Because they serve different purposes: The IPFQR program is a CMS initiative linked to federal reimbursement, while HBIPS is part of the Joint Commission’s accreditation process for hospitals. 

Joint Commission visits

When Joint Commission surveyors visit your hospital, they look for adherence to IPFQR and HBIPS measures. You might ask why the Joint Commission does the visits and not CMS, given that CMS is the payer. The reason is that the Joint Commission works so closely with CMS, using the same or overlapping standards, that CMS accepts Joint Commission accreditation as a sign that the hospital is compliant with CMS standards and is thus eligible to receive Medicare ­reimbursement. 

Current IPFQR and HBIPS measures

These are some measures your hospital collects and reports on:

IPFQR measures

• Screening for metabolic disorders: Assessing metabolic indicators such as HgbA1c levels, especially for patients on antipsychotic medications
• Tobacco use treatment: Initiating nicotine cessation treatments, like nicotine gum or patches, for new patients who smoke
• Other measures: Treatments focusing on alcohol use disorders and the administration of ­immunizations, among others

HBIPS measures

• HBIPS-1: Screening for violence risk, substance use, psychological trauma history, and patient strengths ­completed
• HBIPS-2: Hours of physical restraint use
• HBIPS-3: Hours of seclusion use
• HBIPS-5: Patients discharged on multiple antipsychotic medications with appropriate justification (discontinued for 2024; see below)
• HBIPS-6: Postdischarge continuing care plan created
• HBIPS-7: Postdischarge continuing care plan transmitted to next level of care provider upon discharge

Elimination of HBIPS-5 measure

For 2024, the HBIPS-5 measure requiring justification for the prescription of multiple antipsychotic medications at discharge has been discontinued (www.tinyurl.com/dnhpxkem). This change acknowledges recent findings showing that some patients benefit from using more than one antipsychotic medication. It’s encouraging to see policy updates catching up with current clinical evidence, although one might argue that the pace of evolution could be quicker. If the HBIPS-5 measure still appears in your hospital’s discharge measures, it could be for several reasons.

Data reporting cycles: There might be a lag between the official discontinuation of the measure and the implementation of this change in hospital reporting systems. Hospitals often have established data collection and reporting cycles that may not immediately reflect changes in national standards.

Hospital policies: Some hospitals may continue monitoring certain measures internally, even if they are no longer required for external reporting. This could be for quality improvement purposes or to maintain consistency in data ­collection.

Update delays: The hospital’s electronic health record systems and reporting tools might not have been updated yet to reflect the change. Updating these systems can take time and may require coordination between multiple departments and external vendors.

The consequences of not meeting the measures 

What happens if you fail to meet IPFQR and HBIPS standards? The ramifications can be significant, affecting everything from a hospital’s financial health to its reputation and patient care quality. As these metrics become more publicly accessible, hospitals that fall short may lose patients to higher-performing facilities.

Carlat Verdict 

if you’re frustrated by multiple emails from your compliance department, keep in mind that they are necessary actions to comply with regulations, ensuring hospital remains in good standing and reimbursed by insurance. Fortunately, the measures get updated to reflect current clinical evidence, as seen with the discontinuation of HBIPS-5, meaning you no longer need to justify the use of multiple antipsychotics at discharge.