Welcome to this introductory session on the Quality Measure Analysis and Quality Improvement. I'm Melody Malone, a quality improvement consultant with TMF Health Quality Institute, and I'm happy to bring this session to you today. Our objectives are to define the quality measures, understand the quality measure reports, or the QMs, and to identify the relationship between the minimum data sets assessments, or the MDS, and the quality measures.
But here's my disclaimer-- I am not an MDS expert, so I'm going to always encourage you to use all of the manuals and resources available to you. They include the Resident Assessment Instrument User's Manual, or the RAI manual-- I often call it the MDS manual-- the MDS 3.0 Quality Measures User's Manual, the Quality Measure ID Manual, as well as the Five-Star Quality Rating System Technical User's Guide.
You can reach all those resources through the TMF website as well as links on the TMF website. In addition, I encourage you to use our wonderful Texas MDS program staff. You have both Brian Johnson and Cheryl Shiffer as resources to you. Please use them.
So let's get into how the quality measures are used. Well they were developed by the National Quality Forum and CMS. And there's lots of different people that use them. The Texas Quality Reporting System, or the QRS, isn't using the quality measures right now, but we anticipate they will in the future. I'm recording this in February of 2014, so we'll see when they get turned on. The CMS CASPER system uses 17 quality measures, the CMS Nursing Home Compare uses 18. That's the federal public website. Within that site is the Five-Star Quality Rating System, which uses nine other quality measures. The survey process uses them, as well as the new National Nursing Home Quality Care Collaborative Quality Composite Measure Score.
The Five-Star Quality Rating System utilizes nine quality measures. Seven are long-stay quality measures and two are short-stay. You can find more detail in the Five-Star Quality Rating Guide.
The survey process specifically directs the surveyors in Appendix P to look at the quality measure report and identify those quality measures in the 75th percentile in the nation as potential problem areas for investigation. When they do that, then they look at the resident level report to select residents that have those quality measures as potential concerns.
The New National Nursing Home Quality Care Collaborative Quality Composite Measure Score actually uses 13 quality measures. The last 2% of residents assessed and appropriately given the flu or the pneumonia vaccine are not available to you currently under quality measure reports; however, I bet that you could track back separately and then you could figure out your quality measure composite score.
But the quality measures reports really need to be used by you. They can help you identify what might be a problem in your facility. You can then use them to help search for correlation and to help understand the impact of a single click on the MDS. I also want you to appreciate this is how the world views you. But the good news is this is all retrospective. So you can use your history and your quality measures to help propel you in the future as you work through the quality improvement process.
So let's get into how you find your reports. It kind of depends upon how you submit your MDSs. If you submit through your MDS software, you may get to the reports a different way. If you submit through the keys or the QIES system, then you'll use the CASPER Quality Measure Report page. So either way, I'm going to encourage you to always select the package reports. When you select the package reports, you'll get three of these four. You'll get the Facility Characteristics Report, the Facility Quality Measure Report, the Resident Level Quality Measure Report. You may choose to look at the submission statistics as well. If you do, just request that report separately.
Once you know what reports you want to select, in the key system you'll just have to put in your facility name or your ID and then the beginning and the ending date of the report. I'm going to always encourage you to select a six-month data sample, and if you're using the key systems, it automatically uses that six-month sample. And then you just hit the Submit. Once you do that, your quality measures reports will end up on your Folders page. And you may actually have multiple folders for your facility. So be a little patient. It takes a little bit for them to generate, just a few moments. And you may have to check multiple folders to find out where they actually hit.
The quality measures that you'll see at your facility level today includes 17 quality measures that are stratified into short stay and long stay quality measures. So let's discuss short stay versus long stay. It has to do with the cumulative, or total, days in facility. It does not include any days when the resident was out of your facility, like hospital or at home. A short stay resident has a total cumulative days in facility of 100 days or less. A long stay resident on the quality measure report has 101 days or more in your facility. And these are mutually exclusive, which means on any given report, the resident is only in one category. They are either a short stay resident or a long stay resident.
So let's look at your facility quality measure report. I hope you have your copies of your reports in front of you. I'm going to always encourage you to begin by looking at the report period. Make sure that for all the pages that you're looking at, you've got the same reporting period. Then always be sure you're pulling that six-month report period. If you do not, the quality measures will not all calculate correctly. So you won't really be looking at the same report that your surveyors are looking at. So you want to always make sure you're looking at that same report.
Then the next thing is, you'll notice that every quality measure on the left hand side going down is stratified into short stay or long stay. And again, you're only seeing a portion of the report here. That short stay and long stay is designated by the S.
Then going across the page, you have the measure ID, and every facility has an ID number. The num, or the numerator-- the numerator is all the residents that could have triggered or who did trigger for that quality measure. So in this case, for self-reported moderate to severe pain-- short stay-- there were 12 residents that actually triggered in the numerator as having that problem.
So keep in mind these are all negative, right? They are all potential problems. Having pain isn't a good thing. In the denominator, that's all the residents who could have triggered. So that's 21. So the numerator, we had 12 residents out of the denominator of 21 who could have triggered. That gives us our facility observed percent of 57.1. If there were an adjustment for this, we would see that in the facility adjusted percent. And I'll explain that in a little bit. Then there's a comparison group state average and national average. And then you see the national percentile.
And I want you to read after percentile ranking. Where do we rank in the country? If you think about it on a scale of zero to 100, where zero is good and 100 is the bottom of the barrel, you want to always be closer to the top, right? Kind of like you want to be in the top 10 performance.
And look at this facility's new and worsened pressure ulcers for short stay. They have zero in the numerator, out of a denominator of 31, gives them a zero percent, gives them a national percentile ranking of zero. So yay! They're in the top 0% performance in that country. That's great. But for their pain, both short stay and long stay, they're really not doing so hot. They're in the bottom 98th percentile for short stay and 93rd for percentile long stay. That indicates to me that maybe pain is an opportunity for improvement.
So the basic calculation is pretty simple. It's the numerator, or those residents with the problem, divided by the denominator, all of those who could have had the problem. Times that by 100, and that gives you the percentage. And here you see, for pain-- short stay-- we've been discussing, 12 divided by 21 gives us a 0.571, times 100 is 57.1 for our facility observed percent.
Now let's look at the resident level report. This is where you can identify all of your residents who triggered for a problem. Again, you always want to look at your report period. And there are a couple of unique things on this report. The quality measures actually go across the page left to right, and the residents go down the page top to bottom. And then on the far right you'll also see a quality measure count. So in this case, we can see for resident A-1, they triggered for falls-- long stay-- anti-psychotic med-- long stay-- and behaviors and symptoms affecting others-- long stay-- for a total quality measure count of three.
Now this is where we can really begin looking at, do we have correlation? So did the fall happen because of the anti-psychotic medication? Or did the behavior cause the fall? Or did the anti-psychotic med actually make the fall happen and then we had some behaviors? Or who knows? This is where you have to do your analysis of your quality measure reports.
But there's another unique thing on this report that I want to point out to you. And it's the third column from the left. It's the A0310A/B/F. And what that's referring to is the reason for assessment or the type of assessment. So the A refers to the Federal OBRA Reason for Assessment, the B is the PPS Assessment, and the F is the OBRA and the PPS Entry and Discharge Reporting. So when you see those numbers in that column, and you'll know what MDS it was triggering off of.
Now this report I really love. This is the Facility Characteristics Report. And it does just that. It tells you all about the characteristics of your building. Again, you're just seeing a snapshot of the report here, but it tells you how many men, how many women, what's your age breakdown, how many folks are on hospice, how many residents have a psychiatric diagnosis. So it gives you lots of good information and could give you a window into your facility and maybe some quality improvement opportunities.
But in order to fully analyze your Quality Measure Report, you need to go to the Quality Measure User's Manual. Identify the measure specification. Within the measure specification, it identifies every MDS item that triggers, excludes the resident, or excludes the resident for that quality measure. So you'll have to then go to the REI manual for the MDS items listed and determine, how are we doing? If you're looking at a specific resident, like we were looking at resident A-1, well maybe we had a point and click here, and they really didn't have a fall. Or perhaps when coding, someone did not understand all aspects of that item, that MDS item, and didn't code it accurately to this MDS manual, or maybe didn't understand the ARD, or the Assessment Reference Day.
So we have to look at all of that to determine what is our quality improvement opportunity. Do we really have a quality improvement opportunity? But I have really good news for you. When you're looking at your quality measure reports, I want you to always remember that the initial MDS is excluded in all quality measures. So the first MDS the resident has is not included. The target MDS, the one that's in that A0310A/B/F, depends upon the resident's status as a long stay or short stay, whether or not they've been discharged, and the individual quality measure specifications.
Then there's something called exclusions. I mentioned this earlier. Exclusions from the MDSs actually are written into your measure specification. All quality measures have exclusions except the pneumonia measures. And if the resident is excluded from the denominator, then they're not going to trigger in the numerator. So you really want to understand exclusions for each and every individual quality measure specification, because they are different. And then you'll know whether or not the resident could have even triggered.
Then there's something called covariates. There's only three quality measures that actually are adjusted using resident level covariates. There are new and worsened pressure ulcers-- short stay-- self-reported moderate to severe pain-- long stay-- and catheter inserted and left in their bladder-- long stay. A covariate is found to increase the risk of the outcome, and therefore it helps to support an adjustment if the resident triggers for that quality measure and they have the covariate.
So once you understand and you've selected a quality measure to look at, what you have to do is do that deep analysis. Look at that quality measure specification, read the MDS manual, and look at all aspects of that measure specification, your quality measure report, to determine which residents are in, who was excluded. Did anybody have covariates? And then figure out, what's the real reason why our performance did not meet our expectations? Because in our example, we know nobody wants to be in pain. So that would be something we would want to really look at.
Once we identify our root cause, then we can move to the model for improvement. So what are we trying to accomplish? Decrease resident self-reported pain. How do we know the changes and improvement? Well, we're going to measure data. You can set a goal based upon your quality measure data, or you can even set your goal internally and track your data internally, as it will be a much faster turnaround time for you in your quality measures reports.
And then what change can we make that will result in an improvement? It really depends upon your root cause analysis. So once you determined that test of change, you'll develop your Plan, work your Plan in the Do phase, Study your results, and then Act on those results.
We have much more information in our QAPI video resources on our website that you can use to help you with root cause analysis and the model for improvement. And we'll also be doing future quality measure session. We're going to break down every quality measure and go through it in detail. And we hope through using these shorter, easy-to-learn session, and it will help you and your team to really review your quality measure report, determine what quality improvement efforts you want to begin working on, and get busy working those.
So, I have a challenge for you to do your next steps. Download the Quality Measure User Manual. If you don't already have it, I encourage you to get it and use it. Begin learning your quality measure specification. Begin pulling your quality measures with a six-month reporting period. Select a quality measure to learn more about. And check out our website for more tools and resources. We're available to help you as you work through your quality improvement project and look forward to hearing about your results. Have a blessed day.