Quality Indicators for Psychiatry/Mental Health Topic Web Address Source/Site Site Behavior and Behavior Mechanisms http://www.qualitymeasures.ahrq.gov/browse/by-topic- http://www.qualitymeasu - #182 indicators detail.aspx?id=1179&ct=2 NQMC res.ahrq.gov/ Behavior Disciplines and Activities - http://www.qualitymeasures.ahrq.gov/browse/by-topic- http://www.ahrq.gov/qu #200 indicators detail.aspx?id=5722&ct=2 NQMC al/measurix.htm Mental Disorders - #2 indicators http://www.qualitymeasures.ahrq.gov/browse/by-topic- detail.aspx?id=1180&ct=2 NQMC Psychological Phenomena & http://www.qualitymeasures.ahrq.gov/browse/by-topic- Processes - #73 indicators detail.aspx?id=23011&ct=2 NQMC Psychiatry/Mental Health NQF Endorsed Measures - #17 http://www.qualitymeasures.ahrq.gov/browse/nqf- endorsed.aspx?term=psychiatry%20mental%20health NQMC Research Findings on Mental http://www.ahrq.gov/research/mentalix.htm NQMC A Summary of the National Strategy for Quality Improvement http://www.gwumc.edu/healthsci/departments/nursing/naq http://www.gwumc.edu/ in Health Care Released c_documents/Summary_of_the_National_Strategy_for_Qual healthsci/departments/nu ity_Improvement_in_Hea.pdf NAQA rsing/naqc/index.cfm Mental Health Measures from the National Quality Forum - #36 http://www.qualityforum.org/QPS/QPSTool.aspx?Keyword=mental%2 0health#qpsPageState=%7B%22TabType%22%3A1,%22TabContentTyp e%22%3A1,%22SearchCriteriaForStandard%22%3A%7B%22TaxonomyI Ds%22%3A%5B%5D,%22SelectedTypeAheadFilterOption%22%3A%7B %22FilterOptionLabel%22%3A%22mental+health%22,%22FilterOption s%22%3A%5B%7B%22FilterItemID%22%3A261,%22TypeOfTypeAhead FilterOption%22%3A4,%22TaxonomyType%22%3A0%7D,%7B%22Filter ItemID%22%3A14345,%22TypeOfTypeAheadFilterOption%22%3A2,%2 2TaxonomyType%22%3A0%7D%5D,%22SearchType%22%3A0,%22Ass ociatedStandardCount%22%3A0,%22ID%22%3A0,%22IsNew%22%3Atr ue,%22IsActive%22%3Afalse,%22IsDeleted%22%3Afalse,%22IsLocked %22%3Afalse,%22IsLoading%22%3Afalse%7D,%22PageSize%22%3A%2 225%22,%22OrderType%22%3A3,%22OrderBy%22%3A%22ASC%22,% 22PageNo%22%3A1%7D,%22SearchCriteriaForForPortfolio%22%3A%7 B%22Tags%22%3A%5B%5D,%22FilterTypes%22%3A0%7D,%22ItemsTo Compare%22%3A%5B%5D%7D NQF Agency for Health Care Research Statistical Benchmarks for Quality Measures of Mental Grant # R01-HS10303-02S2, http://www.cqaimh.org/B and Quality Substane Abuse and Health and Subtance-Related Care enchmarks%20for%20Qua lity%20Measures%20SAM Mental Health Services HSA.pdf Administration Center for Quality Assessment and Quality Measures for Mental Health Care: Results This work was supported http://www.cqaimh.org/P Medical Care Research and Improvement in Mental Health, from a National Survey by grants by the National DF%20Copy%20of%20MC Review, Vol. 57 Supplement 2, RR%20paper/MCRR%20p Cambridge Hospital and Harvard Institute of Mental Health df.pdf (2000) 136-154 © 2000 Sage Medical School (K08-MH001477), the Publications, Inc. Agency for Healthcare Research and Quality (R01- HS10303), the Substance Abuse and Mental Health Services Administration, and the Evaluation Center@HSRI National Quality Measures Clearing House retrieved from: http://www.qualitymeasures.ahrq.gov/browse/nqf-endorsed.aspx?term=psychiatry%20mental%20health on January 8, 2012 MEASURE SOURCE Bipolar disorder: the percentage of patients STABLE (STAndards for BipoLar Excellence) diagnosed and treated for bipolar disorder who are performance measures. Boston (MA): Center for NQMC:003506 Any setting monitored for change in their level-of-functioning in Quality Assessment and Improvement in Mental response to treatment. Health; 2007. various p. Bipolar disorder: the percentage of patients STABLE (STAndards for BipoLar Excellence) diagnosed with bipolar disorder and treated with an performance measures. Boston (MA): Center for atypical antipsychotic agent who receive at least one Quality Assessment and Improvement in Mental NQMC:003501 Any setting screening for hyperglycemia within the initial 16 Health; 2007. various p. weeks of treatment
Bipolar disorder: the percentage of patients STABLE (STAndards for BipoLar Excellence) diagnosed with bipolar disorder who receive an performance measures. Boston (MA): Center for NQMC:003491 Any setting initial assessment that considers the risk of suicide Quality Assessment and Improvement in Mental Health; 2007. various p. Bipolar disorder: the percentage of patients with STABLE (STAndards for BipoLar Excellence) bipolar disorder who receive an initial assessment performance measures. Boston (MA): Center for NQMC:003493 Any setting that considers alcohol and chemical substance use Quality Assessment and Improvement in Mental Health; 2007. various p. Child and adolescent major depressive disorder: Physician Consortium for Performance percentage of patients aged 6 through 17 years with Improvement®. Child and adolescent major a diagnosis of major depressive disorder with depressive disorder physician performance documented evidence that they met the DSM-IV measurement set. Chicago (IL): American Medical criteria [at least 5 elements with symptom duration Association (AMA); 2008 Sep. 30 p. [13 references] of two weeks or longer, including 1) depressed NQMC:004437 Child Adolescent mood (can be irritable mood in children and adolescents) or 2) loss of interest or pleasure] during the visit in which the new diagnosis or recurrent episode was identified. Depression: the percentage of patients diagnosed STABLE (STAndards for BipoLar Excellence) with unipolar depression who receive an initial performance measures. Boston (MA): Center for NQMC:003494 Any setting assessment that considers alcohol and chemical Quality Assessment and Improvement in Mental substance Health; 2007. various p. Depression: the percentage of patients presenting STABLE (STAndards for BipoLar Excellence) with depression who were assessed, prior to the performance measures. Boston (MA): Center for initiation of treatment, for the presence of prior or Quality Assessment and Improvement in Mental NQMC:003490 Any setting current symptoms and/or behaviors associated with Health; 2007. various p. mania or hypomania.
Diagnosis and management of attention deficit Institute for Clinical Systems Improvement (ICSI). hyperactivity disorder (ADHD) in primary care for Diagnosis and management of attention deficit school age children and adolescents: percentage of hyperactivity disorder in primary care for school- patients newly diagnosed with ADHD whose medical NQMC:005999 age children and adolescents. Bloomington (MN): Child Adolescent record contains documentation of DSM-IV-TR or Institute for Clinical Systems Improvement (ICSI); DSM-PC criteria. 2010 Mar. 72 p. [128 references]
Institute for Clinical Systems Improvement (ICSI). Diagnosis and management of attention deficit Diagnosis and management of attention deficit hyperactivity disorder (ADHD) in primary care for hyperactivity disorder in primary care for school- school age children and adolescents: percentage of age children and adolescents. Bloomington (MN): patients treated with psychostimulant medication NQMC:006000 Child Adolescent Institute for Clinical Systems Improvement (ICSI); for the diagnosis of ADHD whose medical record 2010 Mar. 72 p. [128 references] contains documentation of a follow-up visit at least twice a year. Hospital-based inpatient psychiatric services: the Specifications Manual for Joint Commission percentage of patients discharged from a hospital- National Quality Core Measures [Version 2011A]. Hospital Inpatient Psychitaric based inpatient psychiatric setting on two or more NQMC:006326 Oakbrook Terrace (IL): The Joint Commission; 2010 Setting antipsychotic medications with appropriate Dec. HBIPS-1 to HBIPS-270 p. justification. Hospital-based inpatient psychiatric services: the Specifications Manual for Joint Commission percentage of patients discharged from a hospital- National Quality Core Measures [Version 2011A]. Hospital Inpatient Psychitaric based inpatient psychiatric setting on two or more NQMC:006325 Oakbrook Terrace (IL): The Joint Commission; 2010 Setting antipsychotic medications. Dec. HBIPS-1 to HBIPS-270 p.
Hospital-based inpatient psychiatric services: the Specifications Manual for Joint Commission percentage of patients discharged from a hospital- National Quality Core Measures [Version 2011A]. Hospital Inpatient Psychitaric based inpatient psychiatric setting with a continuing NQMC:006327 Oakbrook Terrace (IL): The Joint Commission; 2010 Setting care plan created Dec. HBIPS-1 to HBIPS-270 p. Hospital-based inpatient psychiatric services: the Specifications Manual for Joint Commission percentage of patients discharged from a hospital- National Quality Core Measures [Version 2011A]. Hospital Inpatient Psychitaric based inpatient psychiatric setting with a continuing NQMC:006328 Oakbrook Terrace (IL): The Joint Commission; 2010 Setting care plan provided to the next level of care clinician Dec. HBIPS-1 to HBIPS-270 p. or entity. Hospital-based inpatient psychiatric services: the Specifications Manual for Joint Commission total number of hours that all patients admitted to a National Quality Core Measures [Version 2011A]. Hospital Inpatient Psychitaric hospital-based inpatient psychiatric setting were NQMC:006324 Oakbrook Terrace (IL): The Joint Commission; 2010 Setting held in seclusion. Dec. HBIPS-1 to HBIPS-270 p.
Hospital-based inpatient psychiatric services: the Specifications Manual for Joint Commission total number of hours that all patients admitted to a National Quality Core Measures [Version 2011A]. Hospital Inpatient Psychitaric hospital-based inpatient psychiatric setting were NQMC:006323 Oakbrook Terrace (IL): The Joint Commission; 2010 Setting maintained in physical restraint. Dec. HBIPS-1 to HBIPS-270 p.
Hospital-based inpatient psychiatric services: the Specifications Manual for Joint Commission percentage of patients discharged from a hospital- National Quality Core Measures [Version 2011A]. Hospital Inpatient Psychitaric based inpatient psychiatric setting with a continuing NQMC:006328 Oakbrook Terrace (IL): The Joint Commission; 2010 Setting care plan provided to the next level of care clinician Dec. HBIPS-1 to HBIPS-270 p. or entity. Mental health: percentage of discharges for National Committee for Quality Assurance (NCQA). members 6 years of age and older who were HEDIS® 2011: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington hospitalized for treatment of selected mental health (DC): National Committee for Quality Assurance NQMC:006233 disorders and who had an outpatient visit, an (NCQA); 2010. various p. Child Adolescent/Inpatient intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 30 days of discharge CMS Approved NQF Measure Measure Name CMS No. steward (dagger) Program Used Date Pub Definitions Approved Hedis, Healthcare http://www.gpo.gov/fdsys/pkg/FR- CMS N/A NCQA BMI Measurement homes 1/4/2012 2012-01-04/html/2011-33756.htm Medical Assistance Approved with Smoking MU1, HEDIS, NCQA, http://www.gpo.gov/fdsys/pkg/FR- CMS 0027 NCQA Cessation accreditation 1/4/2012 otherwise, NA is used. 2012-01-04/html/2011-33756.htm
Screening for Clinical PQRS, CMS, QIP, Health Approved Depression and FU Homes Core, Shared [Dagger] Measure http://www.gpo.gov/fdsys/pkg/FR- CMS 0418 CMS Plan Savings, HEDIS 1/4/2012 Steward: 2012-01-04/html/2011-33756.htm AHRQ--Agency for Approved All Cause Re- Healthcare Research http://www.gpo.gov/fdsys/pkg/FR- CMS N/A NCQA admission HEDIS 1/4/2012 and Quality. 2012-01-04/html/2011-33756.htm HEDIS, NCQA accreditation, CHIPPRA CMS--Centers for Approved FU after admisison Core, Health Home Medicare & Medicaid http://www.gpo.gov/fdsys/pkg/FR- CMS 0576 NCQA for mental illness Core 1/4/2012 Services. 2012-01-04/html/2011-33756.htm
MU1, HEDIS, NCQA, NCQA--National Approved accreditation, PQRS, Committee for Quality http://www.gpo.gov/fdsys/pkg/FR- CMS 0018 NCQA Controlling BP GPRO, Shared Savings 1/4/2012 Assurance. 2012-01-04/html/2011-33756.htm Approved Antidepressant MU1, HEDIS, NCQA TJC--The Joint http://www.gpo.gov/fdsys/pkg/FR- CMS 0105 NCQA Medication Accreditation 1/4/2012 Commission. 2012-01-04/html/2011-33756.htm CHIPRA Core-- Children's Health Insurance Program Approved CMS- Adherence for Anti- Reauthorization Act-- http://www.gpo.gov/fdsys/pkg/FR- CMS N/A QMHAG psychotic Medication VHA 1/4/2012 Initial Core Set. 2012-01-04/html/2011-33756.htm Initiation and Engagement of Alcohol and other Approved drug dependence MU1, HEDIS, Health CMS QIP--CMS Quality http://www.gpo.gov/fdsys/pkg/FR- CMS 0004 NCQA treatment Home Core 1/4/2012 Incentive Program. 2012-01-04/html/2011-33756.htm HOSPITAL-BASED INPATIENT PSYCHIATRIC SERVICES (HBIPS) NATIONAL QUALITY MEASURES Set Measure ID # JCAHO (Hospital Based) Measure Short Name JCAHO
HBIPS-1a Assessment of JCAHO violence risk, substance use disorder, trauma and patient strengths completed- Overall Rate HBIPS-1b Assessment of JCAHO violence risk, substance use disorder, trauma and patient strengths completed- Children (1-9 years) HBIPS-1c Assessment of JCAHO violence risk, substance use disorder, trauma and patient strengths completed- Adolescent (10-17 years) HBIPS-1d Assessment of JCAHO violence risk, substance use disorder, trauma and patient strengths completed- Adult (18- 64 years) HBIPS-1e Assessment of JCAHO violence risk, substance use disorder, trauma and patient strengths completed- Geriatric (>65 years) HBIPS-2a Hours of Restraint JCAHO Use- Overall Rate HBIPS-2b Hours of Restraint JCAHO Use- Children (1-9 years) HBIPS-2c Hours of Restraint JCAHO Use- Adolescent (10- 17 years) HBIPS-2d Hours of Restraint JCAHO Use- Adult (18-64 years) HBIPS-2e Hours of Restraint JCAHO Use- Geriatric (>65 years) HBIPS-3a Hours of Seclusion JCAHO Use- Overall Rate HBIPS-3b Hours of Seclusion JCAHO Use- Children (1-9 years) HBIPS-3c Hours of Seclusion JCAHO Use- Adolescent (10- 17 years) HBIPS-3d Hours of Seclusion JCAHO Use- Adult (18-64 years) HBIPS-3e Hours of Seclusion JCAHO Use- Geriatric (>65 years) HBIPS-4a Patients discharged JCAHO on multiple antipsychotic medications- Overall Rate HBIPS-4b Patients discharged JCAHO on multiple antipsychotic medications- Children (1-9 years) HBIPS-4c Patients discharged JCAHO on multiple antipsychotic medications- Adolescent (10-17 years) HBIPS-4d Patients discharged JCAHO on multiple antipsychotic medications- Adult (18-64 years) HBIPS-4e Patients discharged JCAHO on multiple antipsychotic medications- Geriatric (>65 years) HBIPS-5a Discharge assessment JCAHO and aftercare recommendations are sent to next level of care providers upon discharge- Overall Rate
HBIPS-5b Discharge assessment JCAHO and aftercare recommendations are sent to next level of care providers upon discharge- Children (1-9 years)
HBIPS-5c Discharge assessment JCAHO and aftercare recommendations are sent to next level of care providers upon discharge- Adolescent (10-17 years)
HBIPS-5d Discharge assessment JCAHO and aftercare recommendations are sent to next level of care providers upon discharge- Adult (18- 64 years) HBIPS-5e Discharge assessment JCAHO and aftercare recommendations are sent to next level of care providers upon discharge- Geriatric (>65 years)