The Joint Commission
HBIPS-2 and HBIPS-3 data element calculation example
- Patty Craig
Joint Commission Guide for Data Entry of Chart-Abstracted Measures for Hospitals (HAP/CAH)
- Version 2023: Discharges 01-01-2023 (1Q2023) through 12-31-2023 (4Q2023)
- Version 2024: Discharges 01-01-2024 (1Q2024) through 12-31-2024 (4Q2024); March 2024
- Version 2025: Discharges 01-01-2025 (1Q2025) through 12-31-2025 (4Q2025); January 2025
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Example #1: Determining HBIPS-2 and HBIPS-3 Strata
HBIPS-2 and HBIPS-3 include an overall measure and four strata (sub-population measures), each defined by specific patient age ranges. Every patient is included in the overall measure.
Calculate the data elements for the overall measure and each strata measure: Initial Population, Denominator, Numerator, Number of Unique Patients within the Numerator. See Example #2 for how to calculate each data element. These elements are entered into the Direct Data Submission Platform (DDSP) for the relevant measure.
HBIPS Measures | Patient Age at Time of Event |
|---|---|
HBIPS-2a and 3a (overall measures) | Age greater than and equal to 1 year |
HBIPS-2b and 3b | Age 1 to 12 years, inclusive |
HBIPS-2c and 3c | Age 13 to 17 years, inclusive |
HBIPS-2d and 3d | Age 18 to 64 years, inclusive |
HBIPS-2e and 3e | Age greater than and equal to 65 years |
Patient Age at Time of Event = (Event Date – Birthdate), calculated as a whole Year
Use the month and day portion of Event Date and Birthdate to yield the most accurate age (in years), do not round.
If the Patient Age at Time of Event is zero (0) years, the patient is not included in HBIPS-2 or HBIPS-3 measures.
If the Patient Age at Time of Event is greater than or equal to 1 year, check the Psychiatric Care Setting to confirm inclusion in HBIPS-2 and HBIPS-3 measures.
Ensure Patient Age at Time of Event is calculated correctly when either or both dates fall on Leap Day (2/29).
For more information concerning the data elements Event Date, Birthdate, and Psychiatric Care Setting, refer to the Specifications Manual for Joint Commission National Quality Measures.
Patient # | Event Date | Birthdate | Calculated Patient Age at Time of Event | Psychiatric Care Setting | Member of Overall Measure | Member of Strata |
|---|---|---|---|---|---|---|
1 | 1/1/2025 | 9/4/1959 | 65 | Y | Yes | Strata E: Age >= 65 years |
2 | 1/10/2025 | 7/3/1940 | 84 | Y | Yes | Strata E: Age >= 65 years |
3 | 1/4/2025 | 12/31/1945 | 79 | Y | Yes | Strata E: Age >= 65 years |
4 | 1/31/2025 | 5/15/1957 | 67 | Y | Yes | Strata E: Age >= 65 years |
5 | 1/8/2025 | 1/1/1950 | 75 | Y | Yes | Strata E: Age >= 65 years |
6 | 1/10/2025 | 2/29/1948 | 76 | Y | Yes | Strata E: Age >= 65 years |
7 | 1/3/2025 | 10/31/1947 | 77 | N | No | None |
8 | 1/1/2025 | 9/4/1960 | 64 | Y | Yes | Strata D: Age 18 to 64 |
9 | 1/10/2025 | 9/4/2006 | 18 | Y | Yes | Strata D: Age 18 to 64 |
10 | 1/4/2025 | 8/10/2007 | 17 | Y | Yes | Strata C: Age 13 to 17 |
11 | 1/31/2025 | 6/30/2011 | 13 | Y | Yes | Strata C: Age 13 to 17 |
12 | 1/8/2025 | 2/29/2012 | 12 | Y | Yes | Strata B: Age 1 to 12 |
13 | 1/10/2025 | 11/15/2023 | 1 | Y | Yes | Strata B: Age 1 to 12 |
14 | 1/31/2025 | 1/15/2026 | 0 | Y | No | None |
Example of calculating Patient Age at Time of Event for patient #6:
Event Date = 1/10/2025
Birthdate = 2/29/1948
Start with the years: First, we look at the years between the Birthdate (1948) and the Event Date (2025). This gives us 2025 - 1948 = 77 years.
Check the months and days: Next, we need to see if the Event Date (January 10) has already passed the Birthdate (February 29) in the current year (2025). Since January 10 is before February 29, the person has not had their birthday yet in 2025.
Adjust the age: Because the birthday has not happened yet this year, we subtract one year from the total. So, 77 years - 1 year = 76 years.
Therefore, the person's age in whole years is 76 years.
Example #2: To calculate the data for HBIPS-2 and 3 for all adults 65 and over (strata HBIPS-2e and HBIPS-3e)
All patients are in the same facility, during the month, and are all adults 65 and over (strata HIBPS-2e and HBIPS-3e). These are the only patients in the facility during the month of January 2025 and all events receive a Measure Category Assignment = “E” in the appropriate measure.
This example uses Patients 1 through 6 from Example #1 for how to calculate Patient Age at Time of Event.
Patient # | # of Psychiatric Inpatient Days | # of Leave Days | Patients with Restraints | Restraint Duration (in Minutes) | Patients with Seclusions | Seclusion Duration (in Minutes) |
|---|---|---|---|---|---|---|
1 | 10 | 0 | X | 10 min |
|
|
2 | 15 | 0 | X | 5min (1st restraint) 10 min (2nd restraint) |
|
|
3 | 30 | 1 |
|
| X | 60 min |
4 | 5 | 0 |
|
| X | 15 min (1st seclusion) 10 min (2nd seclusion) |
5 | 10 | 0 | X | 5 min | X | 5 min |
6 | 20 | 1 | No events for the month | |||
TOTALS | 90 Psychiatric Inpatient Days | 2 Leave Day | 3 patients with restraints | 30 minutes | 3 patients with seclusions | 90 minutes |
For more information concerning the data elements Psychiatric Inpatient Days and Leave Days, refer to the Specifications Manual for Joint Commission National Quality Measures.
Psychiatric Inpatient Days = The sum of the number of days each patient was included in the psychiatric inpatient census during the month, including clients on leave status. For the purposes of calculating inpatient days, the admission day (Admission Date) but not the discharge day (Discharge Date) should be counted. The only exception will be for patients who are admitted and discharged on the same day. Such patients will contribute one inpatient day to the calculation. In addition, patients admitted later in the day still contribute one inpatient day to the calculation.
Total Leave Days = Total leave days is the aggregate number of leave days during the month. A leave day is defined as an authorized or unauthorized absence of a Medicare patient from a psychiatric care setting, excluding discharges, during which the patient is absent from the psychiatric care setting at the time of the daily census and is not under the direct supervision of psychiatric care setting staff while absent.
Initial Population is the number of patients in the unit or facility for the month. This number comes from the Census Data, not from the number of patients processed through the Initial Population algorithm. The Initial Population is calculated as whole days, not hours.
To find the Initial Population, we use the formula:
Initial Population = (Psychiatric Inpatient Days – Total Leave Days), calculated as whole Days
For this example: Initial Population = (10-0) + (15-0) + (30-1) + (5-0) + (10-0) + (20-1) = 88.
The number (88) will be reported for HBIPS-2a, HBIPS-2d, HBIPS-3a, and HBIPS-3d Initial Population.
For HIBPS-2b, HBIPS-2c, HBIPS-2e, HBIPS-3b, HBIPS-3c, and HBIPS-3e, the Initial Population is reported as zero (0) because all the patients for the month were adults 18 through 64 years.
Denominator is the same Census Data for the unit or facility for the month that is used to calculate the Initial Population. However, the Denominator is converted to Hours.
To find the Denominator, we use the formula:
Denominator = (Psychiatric Inpatient Days – Total Leave Days) as whole days, then converted to Hours
For this example: Denominator = (10-0) + (15-0) + (30-1) + (5-0) + (10-0) +(20-1)= 88 days * 24 hours = 2,112 hours
This number (2,112 hours) will be reported for HBIPS-2a, HBIPS-2d, HBIPS-3a, and HBIPS-3d Denominator.
For HIBPS-2b, HBIPS-2c, HBIPS-2e, HBIPS-3b, HBIPS-3c, and HBIPS-3e, the Denominator is not calculated or reported because the Initial Population for these strata is zero (0).
Numerator is calculated from patient data that has been successfully processed through the measure algorithm. It is the total monthly minutes (converted to hours, rounded up) related to the event for those cases with a Measure Category Assignment = ‘E’.
For this example:
Numerator for HIBPS-2a and HBIPS-2d (restraint measure) = 30 minutes, converted to hours (0.5) rounded up = 1 hour
Numerator for HBIPS-3a and HBIPS-3d (seclusion measure) = 90 minutes, converted to hours (1.5) rounded up = 2 hours
For HIBPS-2b, HBIPS-2c, HBIPS-2e, HBIPS-3b, HBIPS-3c, and HBIPS-3e, the Numerator is not calculated or reported because the Initial Population for these strata = zero (0).
Number of Unique Patients within the Numerator is calculated from patient data that has been successfully processed through the measure algorithm. It counts the number of patients represented in the Numerator, not the number of events that occurred during the month. If no event occurred, then Number of Unique Patients within the Numerator = zero (0).
For this example:
Number of Unique Patients within the Numerator for HIBPS-2a and HBIPS-2d (restraint measure) = 3 patients
Number of Unique Patients within the Numerator for HIBPS-3a and HBIPS-3d (seclusion measure) = 3 patients
For HIBPS-2b, HBIPS-2c, HBIPS-2e, HBIPS-3b, HBIPS-3c, and HBIPS-3e, the Number of Unique Patients within the Numerator is not calculated because the Initial Population for these strata = zero (0).
Observed Rate is calculated by the DDSP using the entered Denominator and Numerator data.
The formula for HBIPS-2 and HBIPS-3 is:
Observed Rate = ((Numerator / Denominator) * 1,000)
Where the denominator basis is per 1,000.
The Observed Rate is calculated to 4 decimals and round to 3 decimals where 5 rounds up. For stratified measures, an Observed Rate is calculated for each stratum.
For this example:
Observed Rate for HIBPS-2a and HBIPS-2d (restraint measure) =
((1 hour / 2,112 hours)*1,000) = 0.4734 rounded up to 0.473
Observed Rate for HBIPS-3a and HBIPS-3d (seclusion measure) =
((2 hours / 2,112 hours)*1,000) = 0.9469 rounded up to 0.947
For HIBPS-2b, HBIPS-2c, HBIPS-2e, HBIPS-3b, HBIPS-3c, and HBIPS-3e, the Observed Rate is not calculated because the Initial Population for these strata = zero (0)
Continue to the next section: Section 3: Measure Exclusions
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