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  • Measure Summary
  • NQMC:010791
  • Jul 2016
  • NQF-Endorsed Measure

Hospital-based inpatient psychiatric services: the total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were held in seclusion.

Specifications manual for Joint Commission national quality measures, version 2016A. Oakbrook Terrace (IL): The Joint Commission; Effective 2016 Jul 1. various p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: Specifications manual for Joint Commission national quality core measures, version 2015B. Oakbrook Terrace (IL): The Joint Commission; Effective 2015 Oct 1. 327 p.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were held in seclusion.

This measure represents the overall rate. The following rates are also reported:

  • Children age 1 through 12 years
  • Adolescent age 13 through 17 years
  • Adult age 18 through 64 years
  • Older adult age greater than or equal to 65 years

Rationale

Mental health providers that value and respect an individual's autonomy, independence and safety seek to avoid the use of dangerous or restrictive interventions at all times (Donat, 2003). The use of seclusion and restraint is limited to situations deemed to meet the threshold of imminent danger and when restraint or seclusion are used; such use is rigorously monitored and analyzed to prevent future use. Providers also seek to prevent violence or aggression from occurring in their treatment environments by focusing their attention on prevention activities that have a growing evidence base (Donat, 2003).

Evidence for Rationale

Donat DC. An analysis of successful efforts to reduce the use of seclusion and restraint at a public psychiatric hospital. Psychiatr Serv. 2003 Aug;54(8):1119-23. PubMed External Web Site Policy

Specifications manual for Joint Commission national quality measures, version 2016A. Oakbrook Terrace (IL): The Joint Commission; Effective 2016 Jul 1. various p.

Primary Health Components

Psychiatric inpatient; seclusion

Denominator Description

Number of psychiatric inpatient days (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

The total number of hours that all psychiatric inpatients were held in seclusion (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

  • Restraint and seclusion are coercive high-risk interventions used in many psychiatric care settings in order to control aggressive and violent behaviors. The use of restraint and seclusion may result in adverse events including death and permanent loss of function for some patients, as well as staff injuries. The rationale for restraint and seclusion use is not well understood and varies according to the organization's culture and perception on the most appropriate way to handle escalating behaviors. Restraint and seclusion use adversely impacts healthcare organizations, staff, and patients.
  • According to Bergk et al. (2008), rates of seclusion and restraint use vary from 0% to 66%. Reports estimate 50 to 150 deaths per year in the U.S. due to improper monitoring and application. Additionally, acute excited states resulting from restraint or seclusion have been associated with patient deaths. The use of restraint and seclusion creates significant risks for psychiatric patients. Among the most serious risks are: injury or death, retraumatization of patients with a trauma history, loss of dignity and psychological harm.
  • In mental health, violence is considered endemic. The use of restraint and seclusion contributes to a cycle of workplace violence which may claim as much as 23% to 50% of staff time, account for 50% of staff injuries, increase the risk of injury to patients and staff by 60%, and increase the length of stay, potentially setting recovery back at least 6 months with each occurrence. Results from the National Crime Victimization Survey for 1993 to 1999 which was conducted by the Department of Justice showed the annual rate of nonfatal, job-related violent crime against psychiatrists and mental health professionals was 68.2 per 1,000 and 69.0 per 1,000 for mental health custodial workers as compared to 12.6 per 1,000 for works in all occupations.
  • According to Cromwell et al. (2005), the daily cost of care increases with restraint and seclusion use and contributes to significant workforce turnover reportedly ranging from 18% to 62%, costing hundreds of thousands of dollars to several million dollars. The most significant day-to-day cost is the amount of staff time spent managing restraint and seclusion events. The full cost to an organization is unknown due to the lack of research. One state hospital reported savings of nearly $2.9 million since reducing the use of restraint and seclusion by 54% as a result of decreased worker's compensation claims, staff and patient injuries and length of stay costs.
  • Many hospitals and residential programs, serving different ages and populations, have successfully reduced their use and redirected existing resources to support additional staff training, implement prevention-oriented alternatives, and enhance the environment of care. Significant savings result from reduced staff turnover, hiring and replacement costs, sick time, and liability related costs.

Evidence for Additional Information Supporting Need for the Measure

Bergk J, Einsiedler B, Steinert T. Feasibility of randomized controlled trials on seclusion and mechanical restraint. Clin Trials. 2008;5(4):356-63. PubMed External Web Site Policy

Besemer D, Siler J, Vargas LA. Sanctuary longitudinal study: innovation, collaboration and frustration. In: Paper presented at the Alliance for Children and Families National Conference; Baltimore. 2008.

Cromwell J, Gage B, Drozd E, Maier J, Osber D, Evensen C, et al. Psychiatric inpatient routine cost analysis. Baltimore (MD): Centers for Medicare and Medicaid Services; 2005.

Flood C, Bowers L, Parkin D. Estimating the costs of conflict and containment on adult acute inpatient psychiatric wards. Nurs Econ. 2008 Sep-Oct;26(5):325-330, 324. PubMed External Web Site Policy

Florida TaxWatch. Florida State Hospital-Chattahoochee wins award for reduced patient seclusion and restraint. Adaptable achievements from the 2007 Prudential Financial Davis Productivity Awards competition. [internet]. 2008 [accessed 2012 Mar 13].

Friedman RA. Violence and mental illness--how strong is the link. N Engl J Med. 2006 Nov 16;355(20):2064-6. PubMed External Web Site Policy

General Accounting Office (GAO). Extent of risk from improper restraint or seclusion is unknown. (GAO/T-HEHS-00-26). Washington (DC): United States General Accounting Office; 1999.

General Accounting Office (GAO). Mental health: improper restraint or seclusion use places people at risk. (GAO/HES-99-176). Washington (DC): United States General Accounting Office; 1999.

Haimowitz S, Urff J, Huckshorn KA. Restraint and seclusion: a risk management guide. Alexandria (VA): National Association of State Mental Health Program Directors; 2006.

Huckshorn KA. Re-designing state mental health policy to prevent the use of seclusion and restraint. Admin Policy Ment Health. 2006 Jul;33(4):482-91. PubMed External Web Site Policy

Institute of Psychiatry (IOP). The recognition, prevention and therapeutic management of violence in mental healthcare, UKCC. [internet]. London (UK): United Kingdom Central Council; 2002 [accessed 2012 Mar 13].

National Association of State Mental Health Program Directors (NASMHPD). Position statement on seclusion and restraint. Alexandria (VA): National Association of State Mental Health Program Directors (NASMHPD); 1999.

Paxton D. Creating and supporting coercion-free and violence-free treatment environments: The Village Network and the Knox County Children's Resource Center restraint reduction effort. Paper presentation. Columbus (OH): Ohio Association of Child Caring Agencies Learning Community Conference; 2009.

Richter D, Whittington R, editor(s). Violence in mental health settings: Causes, consequences, management. New York: Springer Science+Business Media, LLC; 2006.

Short R, Sherman ME, Raia J, Bumgardner C, Chambers A, Lofton V. Safety guidelines for injury-free management of psychiatric inpatients in precrisis and crisis situations. Psychiatr Serv. 2008 Dec;59(12):1376-8. PubMed External Web Site Policy

Substance Abuse and Mental Health Services Administration. The business case for preventing and reducing restraint and seclusion use. HHS Publication No. (SMA) 11-4632). Rockville (MD): Substance Abuse and Mental Health Services Administration; 2011.

Extent of Measure Testing

Alpha testing was conducted during May and June 2006 at approximately 40 volunteer test sites to assess feasibility and data collection effort. A set of measures was recommended by the Technical Advisory Panel (TAP) to comprise the final test set addressing the domains of Assessment, Patient Safety and Continuity/Transitions of Care.

The Specification Manual for National Hospital Inpatient Quality Measures Hospital-Based Inpatient Psychiatric Services Test Set was finalized in September 2006. In late 2006 a total of 196 hospitals volunteered to participate in the Hospital-Based Inpatient Psychiatric Services (HBIPS) pilot test. Data collection for the test set began with January 1, 2007 discharges and continued throughout December 31, 2007.

During the first quarter of the pilot test, a subset of 39 hospitals was randomly selected to collect and transmit monthly hospital clinical data (HCD) to help assess data quality and data reliability. The data quality study continued with data collection and transmission for the 12 months of 2007. Feedback on data quality was provided to each performance measurement systems vendor submitting HCD.

The final phase of testing consisted of site visits to a sample of participating pilot hospitals to assess the reliability of data abstracted and reported by those hospitals. Reliability test site visits were conducted at 18 randomly selected pilot hospitals. Selection of the test sites was based on multiple characteristics, including hospital demographics, populations served, bed size and type of facility.

All of the HBIPS measures have undergone a rigorous process of public comment, alpha testing and broad-scale pilot testing and are recognized by the field as important indicators of hospital-based inpatient psychiatric care.

Evidence for Extent of Measure Testing

Domzalski K. (Associate Project Director, Division of Healthcare Quality Evaluation, Department of Quality Measurement. The Joint Commission. Oakbrook Terrace, IL). Personal communication. 2010 Nov 16.  1 p.

State of Use

Current routine use

Current Use

Accreditation

Collaborative inter-organizational quality improvement

Internal quality improvement

Pay-for-reporting

Public reporting

Measurement Setting

Hospital Inpatient

Professionals Involved in Delivery of Health Services

Does not apply to this measure (e.g., measure is not provider specific)

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

All patients age one year and older

Target Population Gender

Either male or female

IOM Care Need

Getting Better

IOM Domain

Safety

Case Finding Period

Discharges July 1 through December 31

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Institutionalization

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Number of psychiatric inpatient days

Exclusions
Total leave days

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
The total number of hours that all psychiatric inpatients were held in seclusion

Include patients for whom at least one seclusion event is reported during the month.

Exclusions
None

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

  • Hospital-Based Inpatient Psychiatric Services (HBIPS) Initial Patient Population Algorithm Flowchart
  • HBIPS-3: Hours of Seclusion Use Flowchart

Measure Specifies Disaggregation

Measure is disaggregated into categories based on different definitions of the denominator and/or numerator

Basis for Disaggregation

This measure is disaggregated according to the following age groups:

  • Children age 1 through 12 years
  • Adolescent age 13 through 17 years
  • Adult age 18 through 64 years
  • Older adult age greater than or equal to 65 years

Data Reported As: Aggregate rate generated from count data reported as a ratio.

Scoring

Ratio

Interpretation of Score

Desired value is a lower score

Allowance for Patient or Population Factors

Does not apply to this measure

Standard of Comparison

Internal time comparison

Original Title

HBIPS-3: Hours of seclusion use.

Measure Collection Name

National Quality Core Measures

Measure Set Name

Hospital-Based Inpatient Psychiatric Services

Submitter

The Joint Commission - Health Care Accreditation Organization

Developer

The Joint Commission - Health Care Accreditation Organization

Funding Source(s)

All external funding for measure development has been received and used in full compliance with The Joint Commission's Corporate Sponsorship policies, which are available upon written request to The Joint Commission.

Composition of the Group that Developed the Measure

The composition of the group that developed the measure is available at: http://www.jointcommission.org/assets/1/6/HBIPS%20TAP%20Members.pdf External Web Site Policy.

Financial Disclosures/Other Potential Conflicts of Interest

Expert panel members have made full disclosure of relevant financial and conflict of interest information in accordance with the Joint Commission's Conflict of Interest policies, copies of which are available upon written request to The Joint Commission.

Endorser

National Quality Forum

NQF Number

0641

Date of Endorsement

2016 Jun 10

Measure Initiative(s)

Inpatient Psychiatric Facility Quality Reporting Program

Quality Check®

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2016 Jul

Measure Maintenance

Every six months

Date of Next Anticipated Revision

2017 Jan

Measure Status

This is the current release of the measure.

This measure updates a previous version: Specifications manual for Joint Commission national quality core measures, version 2015B. Oakbrook Terrace (IL): The Joint Commission; Effective 2015 Oct 1. 327 p.

Source(s)

Specifications manual for Joint Commission national quality measures, version 2016A. Oakbrook Terrace (IL): The Joint Commission; Effective 2016 Jul 1. various p.

Measure Availability

Source available from The Joint Commission Web site External Web Site Policy.

For more information, contact The Joint Commission at One Renaissance Blvd., Oakbrook Terrace, IL 60181; Phone: 630-792-5800; Fax: 630-792-5005; Web site: www.jointcommission.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by The Joint Commission on May 30, 2008 and reviewed accordingly by ECRI Institute on July 7, 2008.

This NQMC summary was updated by ECRI Institute on February 24, 2009. The information was verified by the measure developer on April 27, 2009.

This NQMC summary was completed by The Joint Commission on August 27, 2009 and reviewed accordingly by ECRI Institute on February 5, 2010.

This NQMC summary was completed by The Joint Commission on November 16, 2010 and reviewed accordingly by ECRI Institute on March 30, 2011.

This NQMC summary was retrofitted into the new template on June 30, 2011.

This NQMC summary was completed by The Joint Commission on June 10, 2013 and reviewed accordingly by ECRI Institute on October 30, 2013.

This NQMC summary was completed by The Joint Commission on June 27, 2014 and reviewed accordingly by ECRI Institute on September 19, 2014.

This NQMC summary was completed by The Joint Commission on July 21, 2015 and reviewed accordingly by ECRI Institute on September 21, 2015.

This NQMC summary was updated again by ECRI Institute on June 14, 2016. The information was verified by the measure developer on June 29, 2016.

Copyright Statement

The Specifications Manual for Joint Commission National Quality Core Measures [Version 2016A, July 2016] is periodically updated by The Joint Commission. Users of the Specifications Manual for Joint Commission National Quality Core Measures must update their software and associated documentation based on the published manual production timelines.

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