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National Organizations and Initiatives

The Joint Commission (HBIPS)

The Joint Commission has specified “core measures” for hospital-based inpatient psychiatric services. Until 2008, psychiatric hospitals had reported on self-selected measures. Introducing a core measure set for accreditation provides data that can be used at a national level of analysis to identify problem areas, demonstrate quality improvement, and identify other trends. The topics of the measures are: assessment of violence, risk, substance abuse, trauma and patient strengths completed; hours of restraint use; hours of seclusion use; patients discharged on multiple antipsychotic medications [emphasis is documenting adequate clinical rationale for polypharmacy]; and discharge assessment and aftercare recommendations created and provided to community health providers upon discharge. Presently, free-standing psychiatric hospitals are required to utilize the HBIPS measure set, while general medical/surgical hospitals with inpatient psychiatric units are not.

APA has been in a partnership with the Joint Commission, National Association of Psychiatric Health Systems (NAPHS), National Association of State Mental Health Program Directors (NASMHPD), and the NASMHPD Research, Inc. to develop the “core measures.” The HBIPS measure set, submitted to the NQF for consideration, received endorsement on 6 of the 7 measures. HBIPS-1 (Admission Screening) has yet to receive endorsement.

Center for Quality Assessment and Improvement in Mental Health (CQAIMH)

The Center for Quality Assessment and Improvement in Mental Health (CQAIMH) conducts mental health services research and provides quality management services to improve community-based care for individuals with mental health and addictions disorders. Consisting of faculty and staff from the Institute for Clinical Research & Health Policy Studies at Tufts-New England Medical Center, Tufts University School of Medicine and Harvard University, CQAIMH develops methods of quality assessment, studies organizational determinants of quality, and tests strategies for quality improvement.

NCQA/Healthcare Effectiveness Data and Information Set (HEDIS)

The NCQA-developed HEDIS measure set consists of 90 health plan-level measures across six domains of care, including eight measures specifically focused on behavioral health care and several other measures relevant to mental health care.

The National Quality Forum (NQF)

The mission of the NQF is to improve American healthcare through endorsement of consensus-based national standards for measurement and public reporting of healthcare performance data that provide meaningful information about whether care is safe, timely, beneficial, patient-centered, equitable and efficient. As set forth in legislation (e.g., the Affordable Care Act (ACA), the Medicare Access and CHIP Reauthorization Act (MACRA)), NQF-endorsed measures are prioritized for use in federal programs.

APA is a voting member of NQF through APIRE (American Psychiatric Institute for Research and Education). NQF has a Behavioral Health Standing Committee, which reviews and makes endorsement recommendations on mental health-related measures. Several APA members serve on NQF Expert Panels and Committees.

Healthcare Communities is a web-based knowledge management system that provides multiple means for the healthcare quality improvement community to share knowledge and contribute to each other’s QI work. This includes material on mental health.

Centers for Medicare & Medicaid Services (CMS)

CMS’s Quality Payment Program (QPP) is designed to reward physicians for demonstrating a high level of quality of care or participating in new models of care that reward quality and efficiency. More on the QPP and information for psychiatrists can be found on the APA QPP page.

Additional CMS programs of interest to APA members:

Care Compare

The Care Compare Website allows patients and consumers to view performance information about hospitals, clinicians, and other health care providers, based on data from CMS quality measurement programs. serves as a healthcare professional directory on The Physician Compare Web site includes information about physicians and other professionals who participated in the Quality Payment Program (QPP) and those who participated in the Electronic Prescribing (eRx) Incentive Program. CMS is currently working to implement a plan for making information on individual physician performance publicly available through Physician Compare by January 1, 2013.

Additionally, CMS has created the Quality Care Finder as a collection of helpful tools on the website to help consumers research their healthcare options. These online research tools can help Medicare patients and their caregivers compare healthcare providers, facilities, health and drug plans, equipment suppliers and more.

Minnesota HealthScoresSM

A web-based rating program built on data provided by Minnesota health plans as well as data submitted directly by more than 300 medical clinics statewide. It is promoted by MN Community Measurement to accelerate the improvement of health by publicly reporting health care information. The Depression Care Program is based on the DIAMOND collaborative care project in Minnesota, this care program uses the PHQ-9 tool, a nine-item depression scale questionnaire aimed at helping primary care physicians and behavioral specialists diagnose, select and monitor treatment.

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