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Feds to Release 8 Quality Measures for Psych Unit Care

 |  By cclark@healthleadersmedia.com  
   January 16, 2014

Care lapses can hurt psychiatric patients and hospital reputations. Soon-to-be public data on quality measures for these patients will no doubt reflect on general acute care hospitals overall as well as on their behavioral health units.

Not all acute care hospitals with inpatient psychiatric units have experienced patient deaths involving the controversial use of physical restraints.

But federal inspection reports of these critical inpatient service lines show that dozens of institutions have grappled with lapses, and many more show preventable injuries or very close calls. These incidents are emotionally charged, may unfairly paint the hospital as a cruel organization, and often generate front page headlines, or devastating videos.

This is not the way hospitals teams expect to be viewed in their communities.

That's why the upcoming public release of eight measures demonstrating quality of care specific to each of the nation's 1,800 hospital inpatient psychiatric units—a new federal 2% pay–for-reporting program including measures that reveal their use of restraints and seclusion—is certain to highlight behavioral health variability across the country. When these reports are out for public display, they'll no doubt show some facilities performing very well in complex psychiatric care, and others not so well.

The data will also no doubt reflect on the general acute care hospital's overall quality rating for non-psychiatric care as well, for the behavioral health units these hospitals run are usually in the same building, or just next door, not too far from the hospital's emergency room. Who hasn't known a family member or friend who needed intervention during a 72-hour hold?

 

Four of these measures will be reported for the first time on Hospital Compare as soon as April, while others will follow a few months later or next year.

Now let me recall the story of Jeffrey Christopher, a 25-year-old California man who was being treated for schizophrenia at Sharp Grossmont Hospital's inpatient psychiatric unit and had become agitated after playing cards during a visit with his mother. As I reported in 2008:

The unit's workers took Christopher to his room and had him lie down on his stomach. They secured him to his bed with restraints at the wrists, ankles and waist, keeping his head and neck above the mattress. They also gave him several medications for his schizophrenia, including ativan and thorazine. 

Although nurses continuously monitored Christopher, they did from a chair facing his feet instead of following the standard practice of checking a patient's face. One nurse assigned to his room said she saw him "scoot and wiggle himself lower onto the bed until his face was on the mattress," according to a report by the county's medical examiner, who conducted an autopsy on Christopher.

"He then began violently hitting his face against the mattress and metal frame of the bed," and held his breath, the medical examiner's report said. During a staffing rotation, another nurse entered the room and saw that Christopher had turned blue.

The Medicare report said a nurse tried to resuscitate Christopher, but did not follow American Heart Association guidelines because he had not been trained adequately. Christopher died that night.

Congress specifically wants to make caregivers more aware of such dangerous practices, so these new requirements were authorized in the Patient Protection and Affordable Care Act in 2010. Rules finalized by CMS last August specifically governing payment for these 1,800 hospitals paid under the federal Inpatient Psychiatric Facility Prospective Payment System finalized these eight measures. And there are more to come.

So far, psychiatric care providers are generally pleased with the measures. "The CMS focus on using the data developed through these measures to improve the quality and efficiency of care is extremely important," says Joel Yager, MD, chair of the American Psychiatric Association's Council on Quality of Care. "The field has demonstrated over time that these measures have direct applicability to quality and can be used to positively impact the patient care experience."

"This new reporting system will give psychiatric providers the opportunity to demonstrate their quality, as virtually all other specialties in medicine do," says Kathleen McCann, director of quality and regulatory affairs for the National Association of Psychiatric Health Systems, which supports the new requirements.

8 Measures
Six measures have been reported for the first time to CMS specific to adult patients treated in hospital psychiatric units. The first reporting period for these six ran between Oct. 1, 2012 and March 31, 2013. They are:

  • HBIPS-2 – The total number of hours that all patients were maintained in a physical restraint.
  • HBIPS-3 – The total number of hours that all patients were held in seclusion.

Mental health providers should "avoid the use of dangerous or restrictive interventions" such as restraints and seclusion, according to the measures' definitions, because they increase the patient's risk of physical injury as well as psychological harm. They should only be used when the patient is in imminent danger to him or herself, or others, and only when less restrictive interventions have failed.

They are also specifically not to be used to address staff shortages or to be used as a form of discipline or coercion.

  • HBIPS-4 – The number of patients discharged on multiple anti-psychotic medications.
  • HBIPS-5 – The number of patients discharged on two or more antipsychotic medications with appropriate justification.
  • HBIPS-6 – The number of patients discharged who have had a continuing care plan created for them.
  • HBIPS-7 – The number of patients discharged who have had a continuing care plan delivered to the next level of care clinician or entity.

HBIPS 4 through 7 will be posted on Hospital Compare in April. Measures for seclusion and restraint await clarification before they will be reported, perhaps later this year.

The first reporting period for these last two measures ran from April 1, 2013 through Dec. 31, 2013.

  • SUB-1 – The percentage of patients who are screened during their hospital stay using a validated screening questionnaire for unhealthy alcohol use.
  • FUH – The percentage patients discharged who had an outpatient visit, an intensive outpatient encounter or a partial hospitalization with a mental health practitioner with seven days of discharge.

The Sharp Grossmont team that took care of Jeffrey Christopher in 2008, as well as the top hospital executives in that organization's C-suite, were devastated over this case. They went to great lengths to make changes so deaths to psychiatric patients in their care would never happen again.

I haven't heard that it has. But I look forward to the release of this data. I think it will be a surprise to many hospital caregivers who see for the first time how they compare in their care of psychiatric patients.

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