Welcome to this session of the quality measures, the percent of residents assessed and appropriately given the seasonal influenza vaccine short stay on melody Malone, quality improvement, specialist with health quality institutes. And I'm happy to bring you this program today.
The objectives are to review. The quality measures, specification for this measure, the percentage of residents assessed and appropriately given the seasonal flu vaccine short stay and to identify the relationship between the minimum data set or the s and the quality measure.
But here's my disclaimer. I am not an expert always use the resident assessment instrument, user's manual, or the manual, the S3.0 quality measure users name, and the 5 star quality rating system, technical users guide you'll be able to access all of these manuals from our website, specifically, on the quality measure videos series page.
So, let's talk about how this measure is, used the seasonal. I'll say flu vaccine short stay.
You will not find it on your Casper quality measure report, nor is it part of the 5 star quality rating system it does not go into the rating as of this recording and 20 21, you will see it posted publicly on the care, compare Web site. And, of course, as all quality measures are used in a survey process.
There is no reporting via the Casper system at the facility level, or at the resident level, but when this measure updates once a year on your 5 star provider ratings report, it doesn't go into the rating.
But it is there along with other measures that are posted on care, compare, but do not go into the grading.
At the same time that that report comes out a resident level report, comes out to show you who who triggers in the measure and who was a missed opportunity.
But this measure needs to be used by you to help you identify what might be a problem in your facility to search for correlations among other quality measures to understand the impact of a single click, and to appreciate how the world views you.
This is a publicly posted measure, but all of this is retrospective so we can be doing quality improvement today and moving forward today.
So, let's look at this measure this seasonal influence on measure is a short, stay measure. It means cumulative days in facility are equal to or less than 100 days.
So, only days, actually, in the facility, for the resident count to analyze this measure, we need to go to the quality measure user manual and look at the measure specifications.
Then go to the manual and identify if our coding is accurate.
If there's a point and click error or perhaps those who code the MDS items don't understand all aspects of the items. Or understand the through all of that, we can determine if we do have a quality improvement opportunity.
And I'm going to throw caution out here there are for short stay influenza measures and for long stay influence measures. So when you start looking at the resident list, you'll see those.
Long stay and short stay variations we're doing the assessed and appropriately given, which is a difference in how most measures are written.
Most measures are written to the negative. Nobody wants a pressure ulcer. Nobody wants a catheter where we want every resident assessed and appropriately given.
This seasonal influenza vaccine, so this is reported in a positive measure. So you want 100% of your residents assessed and appropriately given.
The vaccine, so let's go to the quality measure user manual and let's look at the measure specifications.
So the 1st thing that's important to understand is this issue of the influences season and at the bottom of the quality measures.
Specification is the note and the note talks about this is calculated only once a year. So it is calculated.
For the season of October 1 through March, 31.
It's only calculated once a year it updates on your 5 star provider rating report with the July update and on care compare typically, with the July update. So it's once a year calculation. So, getting it right is critical. And it's all in are considered.
For short stay residents in that time, period of the season of October 1 through March, 31. so always keep that in mind. So, let's look at the numerator. The numerator includes the residence that.
We're in the facility during the season and had an active in the. So these are residents that either got the vaccine.
In your facility, or outside of your facility, and on the MBs, you would mark those answers in 0 to 50 a, is inside the facility or C is outside the facility. So, they got at 1 place or the other, or they were offered and declined the vaccine, or they were eligible due to a medical Contra indication.
And each 1 of those are answered at their specific MBs items. So, offered and declined at 80 to 5 C or ineligible do them medical contrary indication at 0 to 5 C and either 1 of those is going to get the resident into assessed and appropriately given because we wouldn't give it to someone who declined it or is medically and eligible.
So these are all, or they either got it or offered and declined or medically unable to take it.
The denominator again is going to be all sorts day residents with a selected influenza vaccination assessment. So that feeds back to that October 1 through March, 31 day.
The only exclusion is if a residence age on the target assessment is 179 days or less. So when you're looking at that, that's an infant, right? So.
We wouldn't give a vaccine to the so.Assessed an appropriately given 1 of those 3 answers and you're at a 100% for your short stay resident.
So, let's look at the actual MDS items. So this is where it actually pulls from in the MBs. So a 1 is a yes.
They got it in your facility or C2. 3 or 4 are what I call inclusion, they received it outside the facility they're not eligible Judah medical contraindications or they were offered and declined.
So, 1 of those 4 answers, and the resident is in, meaning they were assessed and appropriately given that question isn't really a question on the, the quality measure, uses these items to create a, that quality measure of assessed and appropriately given.
So, there's a couple of coding tips and 1 of them is at page 9 of course, always read all the coding tips in the manual.
But once the influenza vaccination has been administered to a resident for the current influenza season, this values carried forward until the new.
Influence the season begin, so, keep that in mind and that will help you with your accurate coding. Once you've looked at all of this, and you've identified that you're not at 100% and therefore you do have a problem you want to do your root cause analysis and figure out how does our performance not meet the expectations of 100% of our residents being assessed and appropriately given.
So you would do your root cause analysis and again, there's places that you can go to, to help you find the resident list, you may be able to pull a report out of your incurrent MBs software by pulling those items out of 0 to 5. 0.
You may have an allies or program that can help you look at it the upside to either 1 of these options is you're looking at current residents that may have the potential to correct depending upon whether or not, you're in this season or not.
And to get them vaccinated or to identify what your quality improvement opportunity is, if you cannot get them vaccinated or assessed and appropriately given the vaccine.
The 5 star resident list that I mentioned, the downside to them is they are very old data because it's using that last season.
And so many of those people may have been discharged by now and there's no really potential opportunity to correct. Last season it's already done.
Remember when you're looking for your potential root causes. There may be a point and click error on the MBs or accuracy for coding or completing the MDS.
And then, once you want to look at is what is the reason for the lack of vaccination of the resident.
If we're not getting them vaccinated or we're not getting the questions asked, we need to understand why that's happening and that's going to feed into your root causes.
So you would look to see what our correlations maybe it's to your admission. You've identified that. Wow. We're not even asking the question on admission.
And then if residents are going out, why are we sending them out to the hospital? Is it because they got sick with the flu? So that's an issue and that's an opportunity for us. And are we, having problems with readmissions on our short stay residents?
So our short stay residents are coming in and going out. And is it because they're getting the flu in the meantime and then, lastly, I think a great root cause to look at is if you're having refusals.
Bye, and what is your mechanism to convert a refusal into a yes, not everybody will want the vaccine.
Some people will have the counter indication, but if you have a high number of refusal, this has worked really looking at and trying to determine.
How is this refusal coming about is the person asking the question not clear in explaining things well, to the resident or the residence representative.
Are they biasing the resident, the resident representative in their own decisions by maybe implying for their own personal.
Believe so that's something to consider. Once you've completed your root cause analysis, then you will go to your model for improvement. So what are we trying to accomplish?
Improving our influence, the vaccination rate to 100% for assessed and appropriately given during the flu season. How will we know that? It changes an improvement?
Because we're going to measure our data, we're going to monitor, we're going to collect lists of our residents and ensure that we are getting those jobs done. And then what change can we make that we're results in an improvement?
That really depends upon what your root cause analysis is finding. So, once you have that, then you can do your plan, do steady act cycle for quality improvement and get your vaccination system. Nice and tight.
We have for you, this worksheet for testing change, which is just the model for improvement, pushed out onto a piece of paper. You can find this in our resources on our website.
And I've got some next steps for you, so here's your next steps to review the coding for the MBs items for this quality measure to read the quality measure user manual again, and make sure you understand the measure specification.
Complete your root cause analysis and begin your quality improvement project and be sure to check out our website for tools and resources.
Specifically you want to go to the resources the quality measure video series.
Web page and the vaccine Tools, and we hope that you will watch more of our quality measure video series.
They're all designed to work together and to help your teams move through the process of quality measure review and quality improvement and easy to learn short sessions. And we will update them.
So come back often as updates to the quality measures occur and then, lastly, you are welcome to reach out to us at our email address and age NHnetwork@TMF.org
And to join our website at TMFNetworks.org. We invite you to create an account and reach out to us. If you have any needs.
I hope to see all of you at 100% for assessed and appropriately given this seasonal Influenza vaccine.