Welcome to this session of the Quality Measure Percentage Residence, Assess and Appropriately Given the Pneumococcal Vaccine Short stay.
My name is Melody Malone and I'm a quality improvement specialist with TMF health quality Institute and I'm happy to bring this program to you today. Our objectives are to review the quality measure specifications and they are very specific.
For this percent of residents assessed and appropriately given the vaccine short stay and to identify the relationship between the minimum data set and the quality measure specifications.
But Here's my disclaimer. I am not an expert, so always use the resident assessment instrument, user's manual or the man.
Always use the S3.0. Quality measure user manual and the 5 star quality rating system.
Technical users guide, you can find all of these measures.
Manuals and manual, and the technical users guide manual on our website in the quality measure video series page.
So, let's talk about how this measure is used. You will not see this measure on your Casper quality measure report.
It is not a measure that is part of the 5 star quality rating system. However, you will see it on your 5 star provider rating report.
It is on the page with other measures that are not included in the rating. How ever they are posted on care?
Compare so this measure percentage presence, assessed and appropriately given the pneumococcus vaccine is posted publicly Uncare compare.
And of course, it can be used in the survey process as your surveyors have access to all of the data.
Since it's not on the Casper report, there's no reporting at the facility level, or at the resident level, and kill that 5, star provider rating report comes out.
And this is updated once a quarter when the rest of the quality measures are updated. And there is a resident level report that goes with your 5 star provider rating report. That's the only time you're going to see it.
And find the residents that are missing, and I'm going to explain that.
But really, all of your data needs to be used by you to help you identify what might be a problem to help you search for correlations between measures, to help you understand the impact of a single click.
And, of course, to appreciate how the world views you, because this is public data. But of course, once the data's all.
Posted it is very retrospective and old, but it's still an opportunity for improvement.
So, this measure specifically, today we're looking at is the short stay measure and short stay means cumulative days and facility is equal to our less than 100 days.
So, only days that the facilities actually, in the or the residence, actually, in the facility.
Are counted towards that short stay.
To analyze this measure, you need to go to the quality measure user may know which we're about to do identify the measure specification then go to the manual and identify if your coding is accurate.
Is there a point in click here or do those who code the s, items really understand all aspects of the items and the, a. R. D or the assessment reference date, then you can determine do we have a quality improvement opportunity?
And I am going to caution you here because there are 4.
Short stay numerical quality measures and for long stay quality measure the 1 we're looking at is assessed and appropriately given that is the 1 that's on your 5 start provider rating report and the ones that are posted on care, compare.
This measure is different as well in that it is reported in a positive manner. So residents who do meet the criteria they were assessed and appropriately given the vaccine are considered positive. Right?
We want 100% of our residents assessed and appropriately given the vaccine. So, it's not a negative measures. Most quality measures are written such as nobody wants a catheter nobody wants a pressure ulcer. So we want those close to 0.
So, let's look at the quality measure specification for this measure and this measure reports, the percent of short stay residents.
Does Costco vaccine status is up to date during the 12 month or 40 period so, in the numerator are going to be your residents who have an up to date vaccine status at 0300ais a 1, or they were offered and declined the vaccine as noted by a 2 and 0, 300 B or. They were medically able to take.
The vaccine due to a Contra indication. And the denominator is all short, stay residents as says.
With with a target assessment, the only exclusion are residents whose age on the target assessment is less than 5 years.
So they have not yet reached our 5th birthday on the target date. Those are the only people that are excluded.
So, up to date in this item means right from the manual at page 13 or 14, that in accordance with the current CDC's advisory committee on immunization practices.
Recommendations they are up to date. So is that committee and the manual direct 2 to 3 different websites and.
Out of the CDC in order to look at those recommendations, and I encourage you to go to those websites frequently and look for any changes in the recommendations.
The manual goes on to say on page 14, if a resident received 1 or more vaccinations, and is indicated to get an additional vaccination, that is not yet eligible for the next vaccination.
Because the recommended time interval between vaccines has not lapse. Then 0300ais coded 1 yes.
Indicating that the residents pneumococcus vaccination is up to date so that helps you address that issue of the 1 year between administration.
So, let's go look at the manual and we can see here that if a 1 is a yes and in 0300thenthe residents up to date and if it's a no, then you have to answer in section B.
And if they are not eligible due to medical Contra indication, or it was offered and decline, then these are the 3 inclusions into this assessed and appropriately given.
So, 1 of these 3 answers is going to get you to 100% for each 1 of your residence. If you're not at 100%, you want to look at.
What is the root cause? So why do we not meet that 100% expectation that we would assess every resident and appropriately vaccinate them?
So look in your software for reports, you may be able to pull a report by MBs item. You may have an analyzer program.
That will help you look at what's going on the outside to 1 of these 2 options is you can get more current residents.
Maybe with a potential to correct if the MBs was done, incorrectly, of course, following your company policy and procedure and get vaccinated or identify the quality improvement opportunity.
How did we miss the resident?
You may have a vaccination tracking tool that you could use. Of course, you can use the 5 star resident list but the downside on that is it will be old data and there will be residents who've been missed that.
You may not have the potential to correct. So, looking at your current India software programs, probably going to help you get to your 100% faster, depending upon what your issues are.
Remember, as part of your root causes to look at errors on the MDS and why do we have any coding errors on the MDS and we are only human. So there could be just a point and click error. But we want to look at that.
And what are we doing to validate or India before we completed? And what are the issues regarding accuracy for coding?
And then, of course, part of the root cost would be identifying the reason why there has been a lack of vaccination for the resident.
Are we not asking the questions what's going on those are all part of our root causes and I encourage you to also look for other correlation so there's other vaccine measures influenza and so are we also low influenza and what's happening are we not getting the questions asked and responded to on admission. Maybe there's a reason you're sending residents out to the hospital and they have pneumonia.
And so we're identifying that we've got people going out with pneumonia, they weren't properly vaccinated. What do we need to do about that? And then that's probably driving your readmission. So there's lots of opportunity here to look at correlation.
And then, lastly, I think a very important issue to look at is your mechanism to convert a refusal into a yes.
You know, a lot of times when people are presented the vaccine question, it may not be the best time for them. It may be the individual who's presenting the offer. There may be some implied bias in their. Question to the resident, or in the way that they offered the information.
So look at all of those opportunities as a way to identify, can we convert a refusal into a yes, what is your mechanism or what is your system for making that happen? Then once you've completed your root, cause analysis.
You'll want to move on to your model for improvement. So what are we trying to accomplish?
We want our residents assessed and appropriately given.
The normal vaccine, 100% of the time, how will we know that it changes and improvements.
Because we're going to track our data and then what change can we make that will result in an improvement that all depends upon what your findings for, in your root cause analysis, and then go into your plan to study act cycle for quality improvements.
We've created for you, a worksheet for testing change. You can find this on our in our resources on our website. This is just the bottle for improvement pushed out onto a piece of paper to make it easy for you to document your quality improvement effort.
So, Here's your next steps review the coding for the MBs items for this quality measures. So you really understand that coding read the quality measure users manual.
Specifications again, make sure you understand the measure specification, then complete your root cause analysis and begin your quality improvement project and we encourage you to check out the website for tools and resources specifically to go to the API resources.
The quality measure, video series, web page and our vaccine resources.
And we encourage you to watch the rest of our quality measure video series and easy short.
Sessions hopefully easy to learn and help you and your team.
Through the process of quality measure review and quality improvement, and we do update them as updates to the measures to occur.
I encourage you to reach out to us via email at NHnetwork@TMF.org. If you have any questions and our website is.
TMFNetworks.org. so I look forward to hearing from you that you've gotten your residence to 100% assess and appropriately given the Pneumococcal vaccine.