Welcome to this session in the Quality Measure video series: High-Risk Residents With Pressure/Ulcers Injuries. I'm Melody Malone, a quality improvement specialist with TMF Health Quality Institute. And I'm happy to bring you this program today. The objectives are to review the quality measure specification for long-stay, high-risk residents with pressure ulcers injuries or high risk PU, and to identify the relationship between the minimum data set or the MBS and the quality measures.
But here's my disclaimer. I am not an MDS expert. Always use the Resident Assessment Instrument user's manual, or RAI manual, the MDS 3.0 quality measure user manual, the five-star quality rating system technical user's guide, and the Centers for Medicare and Medicaid Services MDS video training. You can find all those resources located on our website on the quality measure video series page. Just note that they're always subject to change in location and content.
So how is this high-risk pressure ulcer quality metrics used? Well, you're about to see it on a CASPER quality measure report. It is also posted publicly on this CMS Care Compare website. It is one of the measures that goes into the five-star quality rating system. And of course, the surveyors will use it.
But it needs to be used by you to help you identify what might be a problem, to search for correlations, to understand the impact of a single click on your MBS, and appreciate how the world views you. But that's all retrospective. We want to be working proactively in our quality improvement efforts.
So note that this measure has three different titles. On the CASPER Quality Measure report, it's listed as high-risk/unstageable pres ulcer. On the CMS Care Compare website, it's listed as percentage of long-stay, high-risk residents with pressure ulcers. And on your Five-Star Quality Rating report, it's listed as a percentage of high-risk residents with pressure sores. And in the RAI manual, they use pressure ulcers/injuries as does the state operations manual appendix PP, the Guidance to Surveyors.
So let's get into this measure. It is a long stay measure, meaning the cumulative days in facility are greater than or equal to 101 days in facility. This is a mutually exclusive issue. A resident on any given quality measure report is either a long stay-- 101 days or more in your building-- or short stay, 100 days or less. They can't be both measures on the same report.
To analyze the quality measure, you need to go to the Quality Measure user manual, identify the measure specifications. Then go to the RAI manual and identify if your coding is accurate. Was there a point and click error? Does everyone who codes every item of the MBS, understand all aspects of the item instructions in the RAI manual, and the assessment reference date or the ARD. Then you can determine, do we have a quality improvement opportunity.
So let's look at your CASPER Quality Measure report. Currently today, recording this in 2001, you can see that this measure, high-risk unstageable pressure ulcer is the first item in the list. So numerator for this facility is 3. The. denominator is 66. And then you can see the observed and adjusted percents, the state and the National average, and the national percentile. I always add the word, ranking. So this is where you're going to see this when you pull the report.
In the Quality Measure user's manual, this is the measure specifications. It's actually two pages for this measure. So this measure captures the percentage of long stay, 101 days or more in your building, high-risk residents with a stage two, three, or four, or unstageable pressure ulcers. So residents in the numerator-- if they meet that qualification that they have a stage two, three, or four, or any of the three types of unstageable pressure ulcers. They're in the denominator, or if you will, the population being tested, if they meet the definition of high risk.
And high risk is defined as one or more of the following are met. So they have impaired bed mobility or transfers in section G, as coded in three, four, seven, eight. They're in section B in a coma, or on section I at I5600, they have a diagnosis of malnutrition or risk of malnutrition. And again, this measure is used in the Five-Star Quality rating system.
But let's look at exclusions. That's part of the quality measures as well. Who's excluded? The people that are excluded are those residents where the target assessment, meaning the quality measures looking at that assessment, is an OBRA admission assessment, or a five-day PPS assessment. And that makes sense, because this is a long-stay measure.
They're are also not included in the numerator if they did not meet the pressure or conditions and if any of the following are true, which means any of the six MDS items for pressure ulcers and unstageable have a dash. And we don't like dashes on our MDS. So you don't want that exclusion.
So let's look at the MDS items and where this pulls from. So for a stage two pressure ulcer, it pulls from M0300 B1, any number of stage twos. For stage three, it pulls from C1. For stage four, it pulls from D1. And then into the unstageable items-- unstageable related to a non-removable dressing or device at E1. F1 is related to slough and/or Eschar. And then G1 is related to a deep tissue injury.
So any one of those six items will pull the resident into the denominator and the numerator if they are long-stay, especially the numerator. Now, remember the tip. This all has to be within the observation period or the ARD. And remember I mentioned that up front, is a quality improvement opportunity potentially, if people don't understand the ARD.
So let's discuss this issue of high risk. Because this is a measure, I've mentioned it many times, that is looking at long-stay residents that meet the criteria of high risk. So high risk means that they have either one or both of the ADL items as a three, four, seven or eight, at bed mobility, self-performance in section G, or transfers self-performance in section G. I encourage you and your team to really review the RAI manual for all of section G, and ensure that coding for ADLs is correct.
And then the other item-- because one of them is, they're in a coma, in section B. The other or third item is malnutrition or risk of malnutrition. It must be checked off at I5600 for it to put the resident into the high risk category for pressure ulcers. I encourage you again, to go to the RAI manual, all of section I, and read all of that, and really understand how active diagnoses are coded in section I.
Oftentimes I get a question-- since the denominator is 66, in this case how many low risk residents are there? Because this measure stratifies residents into high risk. And that's who's in the denominator into low risk. But you never see the list of low risk. So here's an easy, quick way to do it.
If you look at your largest long-stay denominator, which is usually restraints, falls, and falls with a major injury, subtract that 1 from the denominator for high risk pressure ulcers, you'll find how many low risk residents that you have. So in this case 104 is our largest long-stay denominator, minus 66, our high-risk pressure ulcer denominator, gives you 38 residents that are low risk. And that is a group you would want to evaluate. And are we sure that we have them quoted accurately?
And again, I'm going to say back to ADL coding, back to your malnutrition and risk of coding, is all of that accurate? Now this little opportunity here only applies to doing long-stay calculation. So to go find your residents, you're going to look at your CASPER Quality Measure Resident Level Report. And if there is an x at high risk, unstageable pressure ulcers, then that means they did trigger for this measure, meaning they were coded on the MDS as long-stay and high-risk, and having one of the six types of pressure ulcers at a minimum.
So now, here's your job is to go search for the root cause. Why do we have people triggering in pressure ulcers at all, or when they never did have one? So this is our opportunity to determine when did our performance not meet the expectations. So again, I'm going to refer back to always looking for errors on the MDS first. Because that oftentimes is where the problem is.
So was there a point and click error? We meant to put in a 0, and we put in a 1. Was there accuracy in all of our coding? So think of our ADLs and our diagnosis for malnutrition and risk of. And the ARD-- is everyone coding to the one ARD?
Then, of course, we want to look at what is the reason for someone having a pressure ulcer injury in our facility? That is critical. We should be looking at that. And then are there correlations to other quality measures, like decline in ADLs? Then we would go to our model for improvement and ask our questions-- what are we trying to accomplish? Improve MDS coding or decrease facility-acquired pressure ulcers? How will we know that it changes an improvement? Because we're going to collect data.
And then what change can we make that will result in an improvement, is coming from your root cause analysis. Then you would implement your Plan-Do-Study-Act cycles for quality improvement. We've taken this model and pushed it out onto a piece of paper. You can access this in our QAPI resources on our website. And we would love for you to reach out to us if you need some help with your quality improvement project. But this gives you a way to document your quality improvement efforts.
So here's your next steps. Review the coding for the MDS items for this quality measure. Read the quality measure user manual measure specifications again, and make sure you really understand them. Then, begin your root cause analysis and your quality improvement project. And be sure to check out the website for tools and resources.
You are also welcome to email us if you have any questions at NHnetwork@tmf.org, and our go to our website at, tmfnetworks, with an s.org. And specifically, I direct you to the nursing home, skilled nursing facility network. I hope this program was helpful for you today.