NAPHS and its members are committed to the delivery of responsive, accountable, and clinically effective prevention, treatment, and care for children, adolescents, adults, and older adults with mental and substance use disorders.

Kathleen McCann, R.N., Ph.D., is the association's Director of Quality and Regulatory Affairs, serving as the key contact for both members and policy leaders on a wide range of quality, clinical, accreditation, and regulatory issues.

Learn more about the following quality initiatives and resources:

  • Performance measurement:
  • National Quality Forum participation.
    • NAPHS was approved in 2010 as a member of the National Quality Forum (NQF) and will serve on the Provider Council. NQF-endorsed standards are the primary standards used to measure and report on the quality and efficiency of health care in the U.S., and the organization is recognized as a major force driving continuous improvement of healthcare quality. NAPHS has worked with NQF through the approval process for the Hospital-Based Inpatient Psychiatric Services (HBIPS) core measures and will continue to work with NQF on future measure development. Membership allows NAPHS to have a more active role in identifying measurement priorities and representing the needs of behavioral healthcare organizations within the NQF process.
  • Representation on Joint Commission PTACs. NAPHS holds seats on two key Professional and Technical Advisory Committees (PTACs) within The Joint Commission: the Hospital PTAC and the Behavioral Health PTAC. NAPHS also participates in The Joint Commission's Liaison Network.
  • Smoking cessation and health. NAPHS is working with the National Mental Health Partnership for Wellness and Smoking Cessation to make health and wellness a priority for people with mental illnesses and for the providers who serve them. NAPHS is offering a training with faculty from the Smoking Cessation Leadership Center of the University of California San Francisco to help psychiatric facilities address clinical and policy issues related to smoking cessation.
  • Information technology. NAPHS has formed an Information Technology (IT) Committee to help the association develop public policy strategies on IT issues. NAPHS is also working as part of the Behavioral Health Information Technology Coalition to educate Congress about the need to extend health IT incentives to behavioral health.
  • Training for clinical and administrative staffs (on issues ranging from suicide prevention to safety standards)
  • Learning from Each Other: Success Stories and Ideas for Reducing Restraint/Seclusion in Behavioral Health



NAPHS comment letter to CMS on "Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies”


Joint Commission:  America's Hospitals: Improving Quality and Safety -- The Joint Commission's Annual Report 2015.  See pages 17-19 for HBIPS measures. Also includes Top Performer hospitals.  See a news release for details.


NAPHS comment letter on proposed Medicare hospital outpatient PPS/partial hospitalization program (OPPS/PHP) rates for CY16


NAPHS Action Alert: "IPFQR Tips to Avoid Errors During Submission of Web-based Measure Data for FY2016"


HRSA notice: "Publication of the Revised Guidebook for the National Practitioner Data Bank"


NAPHS comment letter to CMS on proposed rule: "Inpatient Psychiatric Facilities PPS-Update for Fiscal Year Beginning October 1, 2015 (FY16)" (including IPFQR quality measures)


CMS proposed rule: "Medicaid & Children’s Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, Medicaid and CHIP Comprehensive Quality Strategies, and Revisions Related to Third Party Liability." Also see CMS fact sheet.


FGI/NAPHS release:  "Facility Guidelines Institute Is New Publisher for Design Guide for Behavioral Health Facilities; Updated 7.0 edition now available on the FGI website"


NAPHS Action Alert: "New Resources Now Available for the IPFQR Program; Next Webinar is November 20, 2014 at 2pm Eastern"


CMS final rule on the Medicare outpatient prospective payment system/partial hospitalization program (OPPS/PHP) rates for CY15. 


NAPHS Action Alert: October 29 Inpatient Psychiatric Facility Quality Reporting Program National Provider webinar on "A Closer Look at the Measures for Collection CY 2015" at 2pm Eastern. Download slides.


NAPHS Action Alert: Sept. 24 IPFQR National Provider Call at 2pm Eastern on “IPFQR Program Requirements: FY2015 IPF PPS Final Rule.”  Download slides.


NAPHS comment letter on proposed Medicare hospital outpatient prospective payment system/partial hospitalization program (OPPS/PHP) rates for CY15.


CMS final rule:  "Medicare Program: Inpatient Psychiatric Facilities Prospective Payment System - Update for Fiscal Year Beginning October 1, 2014 (FY15).”


NAPHS Action Alert: "QualityNet’s Secure Portal Now Available for IPF Quality Reporting"


Notice of Participation form for IPF Quality Reporting program


CMS proposed rule:  "Medicare Program: Inpatient Psychiatric Facilities Prospective Payment System - Update for Fiscal Year Beginning October 1, 2014 (FY15).” Also see CMS fact sheet.


CMS release: First public reporting of quality measures from inpatient psychiatric facilities launched on Hospital Compare


CMS/CDC/OCR final rule: "CLIA Program and HIPAA Privacy Rule; Patients’ Access to Test Reports"


Order a recording of a special training call on "Reporting SUB-1 (Alcohol Use Screening) in the IPFQR." Also download materials (files are large; please allow time for each to open): 1) Joint Commission PowerPoint; 2) Michael Miller, M.D., PowerPoint; 3) Eric Goplerud PowerPoint; 4) SBIRT Mentor brochure. Also see 5) the Telligen IPFQR newsletterAfter the training, please complete 6) an online evaluation.


CMS: Inpatient Psychiatric Facility Quality Reporting (IPFQR) Quarterly Newsletter (Vol.1.No.1)


NAPHS comments to National Quality Forum on proposed behavioral health measures


CMS final rule: "Medicare Program: Conditions of Participation (CoPs) for Community Mental Health Centers"


Joint Commission releases updated Sentinel Event data updated to June 2013. Link to the full report or view specific sections including 1) a Sentinel Event Data Summary—As of August 1, 2013; 2) Sentinel Event Data—Event Type by Year; and 3) Sentinel Event Data—Root Cause by Event Type.


NAPHS comment letter responding to Senate Finance Committee open letter seeking input on how to improve the US mental health system


NAPHS comments on SAMHSA's National Behavioral Health Quality Framework


NAPHS Alert: "Paper forms available to assist those having difficulty with data submission for the IPF Quality Reporting program." See forms for 1) Notice of Participation; 2) IPF Data Collection paper form; and 3) IPF DACA paper form.


CMS final rules: "Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals...and FY2014 Rates; Quality Reporting Requirements for Specific Providers; ....etc."  (See pages 50887-50901 for IPF quality reporting section.)  Also see 7.30.14 correcting amendment.


Behavioral Briefing: IPFQR Structural/Web-Based Measures Application Now Available


NAPHS comment letter to CMS: "Medicare: ....Quality Reporting Requirements for Specific Providers (CMS-1599-P)"


NAPHS releases first study to examine readmissions within the Medicare Inpatient Psychiatric Facility Prospective Payment System (IPF PPS). View news release and study.


CMS proposed rule on quality reporting requirements for inpatient psychiatric facilities (for FY15 payment determination). See page 27734.


Design Guide for the Built Environment of Behavioral Healthcare Facilities authors receive NAPHS Quality Award on 10th anniversary of the publication


HHS final rule: "Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules"


CMS final rule on quality reporting requirements for inpatient psychiatric facilities (see pages 53644-53680). [View]


NAPHS comments to Office of Surgeon General on prescription medication adherence (in response to 4/5/12 request for information)


HHS final notice: "Medicaid Program: Initial Core Set of Health Care Quality Measures for Medicaid Eligible Adults" [View]


CMS final rule: "Medicare Program; Availability of Medicare data for performance measurement" [View]


NAPHS comments on CMS proposed inpatient psychiatric facilities performance measures required by the Affordable Care Act [View]


NAPHS comment letter to CMS on proposed rule: "Medicare and Medicaid Programs: Influenza Vaccination Standard for Certain Participating Providers and Suppliers" [View]


NAPHS comment letter to AHRQ on "Medicaid Program: Initial Core Set of Health Quality Measures for Medicaid-Eligible Adults" [View]


Joint Commission HBIPS core measures now required of psychiatric hospitals; available to psychiatric units to use


Federal Register notice with comment period: "Medicaid Program: Initial Core Set of Health Quality Measures for Medicaid-Eligible Adults" [View]


Federal Register: Final rule: "Medicare and Medicaid Programs: Changes to the Hospital and Critical Access Hospital Conditions of Participation to Ensure Visitation Rights for All Patients" [View]


Federal Register: Medicare program final rule, including...."Medicaid Program: Accreditation for Providers of Inpatient Psychiatric Services" (large file--please allow time for file to open) [View]


CMS final rule on "Medicare and Medicaid: Hospital participation conditions; patients' rights" [CMS-3018-F] published in the Federal Register. Includes revised regulatory language on the "one-hour rule."


"Hospital Conditions of Participation: Requirements for History and Physical Examinations; Authentication of Verbal Orders; Securing Medications; and Postanesthesia Evalutions (CMS-3122-F)."


About the NAPHS / NASMHPD / NRI Collaboration (.pdf) [View]


News release on the 10/16/02 teaming agreement [View]


RECURRING: PEPPER Training and Resources

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