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Behavioral Health Quality Report

Behavioral Health Services of Baystate Health offer comprehensive mental health, behavioral medicine, and employee assistance programs that are responsive to today's changing healthcare system. We believe that the needs of the patient are best served by when a team of professionals delivers the thoughtful integration of specialized services delivered by a multidisciplinary team of professionals.

In 2007, the Adult Psychiatric Treatment Unit (APTU) at Baystate Medical Center began voluntarily collecting the Hospital-Based Inpatient Psychiatric Services (HBIPS) core measures and reporting the data internally to the Behavioral Health Performance Improvement Committee. The Mental Health Unit at Baystate Franklin Medical Center began data collection in 2008. The HBIPS core measures reflect a collaborative effort among the National Association of Psychiatric Health Systems (NAPHS), the National Association of State Mental Health Programs, and the Joint Commission to improve quality, safety, and performance of hospital-based inpatient psychiatric services.

The five areas in which performance data are collected include:

  • Admission screening for violence risk, substance use, psychological trauma history, and patient strengths (higher is better)
  • Hours of physical restraint use (lower is better)
  • Hours of seclusion use (lower is better)
  • Patients discharged on multiple antipsychotic medications (lower is better)
  • Post-discharge continuing care plan transmitted to next level-of-care provider upon discharge (higher is better)


Baystate Medical Center

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  • We changed the Admission screening/initial psychosocial assessment for violence risk, substance use, psychological trauma history tools from paper based tools to electronically collected (electronic medical record), helping to standardize the documentation and audit process.
  • We are focusing on training all staff in verbal de-escalation strategies, including specialized instruction for an additional staff member that increased expertise and training capacity on the unit.
  • All Psychiatric residents continue to be trained and certified in crisis prevention counseling.

Baystate Franklin Medical Center

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  • BFMC has had continued success with its Threat Assessment Team (TAT) which develops responses to threats of physical hard from patients. The pilot is completed, and there are plans to spread TAT beyond the mental health unit to other units and to other sites within Baystate Health.
  • The Partial Hospitalization Program received full accreditation from the Joint Commission This was the first time that the program was accredited separately from the main hospital due its growing census.

Future Work

Future efforts will include continued emphasis on restraint and seclusion reduction, and on exploring programming enhancements to further expand the treatment options for patients. In addition, future efforts will capitalize on the use of technology to facilitate admission screening and transmission of post-discharge continuing care plans to the next level-of-care provider.

For more information on Quality at Baystate Health

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For more information on Baystate Medical Center

For more information on Baystate Franklin Medical Center