Patients in inpatient psychiatric care are especially vulnerable to physical and psychological harm, but they have largely been excluded from efforts to monitor, understand, and improve quality of care. In 2012, the Centers for Medicare and Medicaid Services (CMS) implemented the Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program to ease inpatient psychiatry into the norms and scrutiny that general hospital care has received for a long time. In a recent study in Medical Care, my co-author and I found that the IPFQR Program has positively impacted restraint and seclusion, reducing the duration of each by about 50% from 2012-2017. Our study is the first and only examination of the IPFQR Program on restraint and seclusion use. 

Morgan C. Shields, PhD is an LDI Associate Fellow and a Postdoctoral Fellow in the Department of Psychiatry’s Center for Mental Health at the Perelman School of Medicine.

The IPFQR Program is a public reporting program that incentivizes psychiatric facilities to report on a suite of quality measures, or else face a 2% payment reduction in their annual Medicare payment rate update. Nearly all facilities in the country participate. Among other measures, the IPFQR Program captures facility-level hours of restraint and seclusion—a salient source for patient harm—for the entire patient population, not just Medicare beneficiaries.

To examine changes in restraint and seclusion, we compared their use between two groups: facilities that had already been reporting these measures to The Joint Commission (“previously exposed”) and those that recently began reporting the measures through the IPFQR Program (“newly exposed”). We also compared restraint and seclusion use between the first year of the program (end of 2012-2013) and all other years (2014-2017), as well as by facility ownership type.  

Among nearly 10,000 observations at 1,841 facilities, the IPFQR Program reduced duration of restraint by 49% and seclusion by 54%. Change in duration of restraint and seclusion did not differ by type of ownership (for-profit, nonprofit, or government). However, among for-profit facilities, fewer facilities reported rates of zero for seclusion after the first year of reporting to the IPFQR Program.

Policy Implications

Our findings have several important implications. First, despite attempts to remove the restraint and seclusion measures from the IPFQR Program, our findings suggest that they are meaningful measures to retain. However, the measures as they currently exist are prone to error. They could be strengthened with a more nuanced assessment of restraint and seclusion that captures the actual number of restraint and seclusion events rather than facility-level hours (i.e., how many lives are impacted); use of debriefing sessions with patients following restraint and seclusion; the type of restraint (chemical versus mechanical); and patient demographic and clinical characteristics.

It is also critical for consumers, policymakers, and payers to understand how use of restraint and seclusion varies not only between facilities, but within facilities, especially in regard to intersecting marginalization (e.g., race, ethnicity, gender, and sexuality). Evidence-based models for preventing and reducing restraint and seclusion suggest that facilities should be tracking such detailed information for internal use. Thus, mandating that facilities report these more detailed data to CMS might motivate improved organizational-level tracking and quality improvement efforts, as well as systems-level scrutiny and accountability.

Second, we were unable to observe the exact actions facilities took to reduce restraint and seclusion. In response to the IPQFR Program, facilities could have implemented evidence-based models of care, thereby strengthening the staff-patient relationship. Alternatively, facilities could have increased their use of sedating medications. To better refine the program, future research will need to describe exactly how organizations are responding to the IPFQR Program as well as its spillover effects on non-targeted quality areas.

Finally, patient-centeredness should be the ultimate goal of the IPFQR Program, particularly in light of reports of unsafe care, dehumanizing care, and lack of patient agency in inpatient psychiatric facilities. Including patient experience and patient-reported outcomes of care in the IPFQR Program would better capture patient-centeredness. This would provide consumers, researchers, policymakers, and payers with a greater understanding of the inpatient psychiatric treatment environment and its impact on patients, as well as more meaningful information that payers, consumers, and families could use while shopping for care.

Ultimately, any serious attempt to systematically reform patient safety in inpatient psychiatry must target the extreme power imbalance between patients and all other actors (i.e., providers, law enforcement, payers, and regulators). Putting the experience and needs of patients at the center through measurement and action will be critical to this effort.

The study, The Effect of Centers for Medicare and Medicaid’s Inpatient Psychiatric Facility Quality Reporting Program on the Use of Restraint and Seclusion, was published in Medical Care in October 2020. Authors include Morgan C. Shields and Alisa B. Busch.