Welcome to this session on the quality measures, the percent of residents who've had a catheter inserted and left in their bladder. I'm Melody Malone, a quality improvement consultant with TMF Health Quality Institute. And I'm happy to bring you this program today.
We'll be reviewing the quality measures specification for this measure, the percent of residents who've had a catheter inserted and left in their bladder long stay. And identify the relationship between the minimum data set or the MDS and the quality measures. But here's my disclaimer. I am not in MDS expert. I'm getting encourage you to always use the tools and resources that you have at your fingertips.
They include the Resident Assessment Instrument User's Manual or the RAI, the MDS 3.0 Quality Measure User Manual, the Quality Measure ID Reporting Module, and the Five-Star Quality Rating System Technical Users Guide. You can find all of those on the cms.gov website, as well as in the video resource page for TMF.
I'm going to also encourage you to reach out to our Texas MDS program staff. They include Brian Johnson, who is the MDS automation and QUIES coordinator and Cheryl Shiffer, the MDS clinical coordinator.
So let's jump into, how is this catheter quality measure used? Well, it is used in every possible way. On the Texas Quality Reporting System, or you may know it as QRS, this measure is part of the calculation for the score on the QRS. You'll find this on your Casper Quality Measure Report, as well as see it on the CMS Nursing Home Compare, which is the federal public website.
It's also one of the nine quality measures that go into the Five-Star Quality Rating. It also is included in the National Nursing Home Quality Care Collaborative Quality Composite Measure Score. And it is also in the survey process. So of the nine quality measures that go into the Five-Star Quality Rating System, this measure, catheter inserted left and left in the bladder, is one of the long stay measures that's included.
And you can see it's also part of the Quality Composite Score. But this needs to be used by you to help you identify what might be a problem in your nursing home, to help you search for correlations, to understand the impact of a single click on your MDS, as well as to appreciate how the world views you. But keep in mind, all this is retrospective. You're going to have to keep concurrent data monitoring as you work through your quality improvement efforts so that you can change your future.
So let's look at this measure. This is the percent of residents who've had a catheter inserted and left in their bladder long stay. Remember, long stay means the cumulative days in facility is equal to or greater than 101 days. Now this issue of long stay and short stay is mutually exclusive.
So on any given report, a resident is either a long-stay resident or a short-stay resident. Never both on the same report. So in this case, this measure is a long stay measure.
When you look at your quality measure report, you'll find it on your Casper Report. And in our case today, this facility report they had five residents in the numerator meaning five residents with a calculator out of a denominator of 66 for a facility-observed percent of 7.6. And look, there is an adjustment of 7%. So we'll discuss that in covariates.
And you can see, against the state and the national average this facility might have a quality improvement opportunity because they're way above the state and national average, which puts them in the bottom percentile ranking in the nation at the 82nd percentile ranking. But in order for us to analyze this and to really understand this measure, we need to go to the Quality Measure User Manual, identify those measure specifications, then go to the RAI Manual an identify are we actually even coding this accurately. Once we do all of that, then we can determine if we have a quality improvement opportunity. And if so, what is it.
So let's look at the Quality Measure User Manual for this measure, which reports the percent of residents who have an indwelling catheter in the last seven days. Indwelling is important. So this is a long-stay measure so we're looking at that long-stay measure where indwelling catheter at MDS item H0100A is a 1, indicating the use of this catheter. Out of a denominator of all long-stay residents with a selected target assessment except those with exclusions.
So let's identify what these exclusions are. Well, the first one is that the target assessment is an admission assessment or a PPS five-day or a return readmission assessment, which makes sense because this is a long-stay measure, right? So with their total days in facility of 101 days or more, we're not going to be coding with that. Or the target assessment indicates that the indwelling catheter status is missing. That's what the dash means. It's missing at H0100A. That would be an exclusion.
An exclusion would be that the assessment indicates the resident also has neurogenic bladder as a diagnosis checked off at I1550 or a 1 or the status is missing for neurogenic bladder. And the same thing for the diagnosis of obstructive uropathy. They do have a diagnosis of obstructive uropathy at I1650 or that is missing. So let's look at these MDS items. So the MDS item H0100A equals 1 means they do have an indwelling catheter and note it includes suprapubic, as well as nephrostomy. So let's look at these.
So the indwelling catheter is for the purpose of continuous drainage of urine. The suprapubic is that catheter that is placed into the bladder through the abdomen. And the nephrostomy tube is inserted through the skin into the kidney. So in any one of these cases and if it's coded at H0100A then that means the resident has a catheter.
But remember we have those two exclusion diagnoses of neurogenic bladder or obstructive uropathy that if the resident has either one of these checked, it will exclude the resident from triggering as having a catheter. So let's look briefly at these diagnoses.
Neurogenic bladder at MDS item I1550 includes the bladder dysfunction, either flaccid or spastic, caused by neurologic damage. Now this may involve the central nervous system, the peripheral nerves, or both. And that's a definition from the Merck Manual.
Obstructive neuropathy at MDS item I1650 is the structural or functional hindrance of normal urine flow. Again, that definition from the Merck Manual. So I encourage you as you're working through your quality improvement efforts to look at why does your resident have this catheter and does the resident have this diagnosis. And if they do have this diagnosis, have we utilized the two-step process for assessment of active diagnosis in the last seven days to code it accurately on the MDS.
Remember, this is a two-step process. And I'm going to encourage you to always use your RAM Manual to help you with that. But remember, we saw that facility adjustment. That had to do with the covariate.
There are three resident quality measures that have resident level covariates, which a covariate is found to increase the risk of an outcome. So we can see that catheter long stay is one of those three. And on our Quality Measures Specification page, we find those covariates on the right.
So there's three covariates. So let's discuss those. The first covariance is where the resident has frequent bowel incontinence on a prior assessment. So at MDS item H0400, bowel continence, they are marked as a 2 or a 3 for frequently incontinent or always incontinent on a prior assessment.
So if they're marked as a 2 or a 3, the covariate is a 1, meaning it will risk adjust the resident. Or it will be a 0, meaning it will not risk adjust the resident if it's a 0 always continent or if it's occasionally incontinent and a number 1 or 9, not rated.
The covariate two deals with pressure ulcers at a stage II, III, or IV on the prior assessment again. Remember, both of these are on the prior assessment. So it's a 1 if the resident has any number of pressure ulcers at a stage II, III, or IV.
So on the MDS it has been put a 1, 2, 3, 4, 5, 6, or 7, the number pressure ulcers at each stage. So if they have a pressure ulcer on a prior assessment at a stage II, III, or IV or any number then the covariate will kick in and the resident will be risk adjusted. If the covariate is a 0 or missing, if it's a 0 in all stages-- a stage II, a stage III, and a stage IV then it will be a 0 as a covariate. Or if it's missing at a II and III and IV. If that wasn't assessed on the prior assessment then the covariate is considered missing and it will not be risk adjusted for that resident.
So the third covariate is if all covariates are missing if there's no prior assessment available, which makes sense because covariate 1 relies on bowel incontinence being present on the prior assessment. Covariate II is the pressure ulcers at stage II, III, or IV on the prior assessment. So it makes sense that if they're missing then there will be no covariate or no risk adjustment.
I'm going to refer you back to the MDS Mentor for December of 2013 on setting the ARD, which is in Chapter 2 of your MDS Manual. I think it's really important that the team understand the ARD in depth so that we ensure that all of our MDSs are accurately coded and that on the prior and the current MDS we can rely on that coding to help calculate the quality measure accurately.
The next quality measure report you would want to look at would be the Resident Level Report. When you look at the Resident Level Report, you'll be able to identify for your residents with a catheter who's coded with the X means that they actually have the catheter. And then as you go across, you can identify what other measures do they trigger for. In this case, anti-psychotic med long stay.
Pressure ulcers on this current MDS that has the catheter, as well as moderate to severe pain. Well, I think if I had a catheter I'd have moderate-to-severe pain too. But I think this gives us a wonderful opportunity to look at what might be correlations going on.
Does the resident have a catheter because they have a pressure ulcer? Did they have pain and that's what caused them to develop the pressure ulcer? What's going on with that anti-psychotic med? Is the catheter driving him crazy? So I think this is a great opportunity for us to look at do any of these measures have a correlation and effect on each other, and are they present or occurring with this resident in some relationship with each other?
Once you do that analysis for all of your residents with a catheter then you want to search for that real root cause and identify why do we have anybody with a catheter inappropriately. Now we know we have two automatic exclusions with the diagnoses of obstructive uropathy or neurogenic bladder, but we always want to be looking at why does anybody have a catheter as we know it increases the risk of infection, right?
So we want to look at those root causes and identify, do we have any errors on our MDS? Could it be just a point and click error? If so, how did that happen? Or accuracy for coding error.
And then what is the real reason for that catheter? And is there a way for us to have addressed that earlier? Is there a way for us to address it now?
Once we know what our root causes for our quality improvement opportunity are then we can go into our model for improvement, which helps us work through the quality improvement process. So what are we trying to accomplish? Decrease inappropriate catheter use. How will we know that it changes an improvement? Well, we're going to measure our data concurrently as we work through our quality improvement efforts so we can see that change.
And then what change can we make that will result in an improvement? We're going to identify those change strategies from our root cause analysis. And once we know what those change strategies might be, we're going to select the one that we want to start with, come up with a thorough plan that gives us our who, what, where, when, how we're going to get it done, along with the measurement strategy. Then go out and work our plan, collect our data, and then study the results of our activities, our quality improvement efforts.
And then decide what do we want to do. Was that test of change successful? Do we need to do something different? Do we need to test it on a wider scale? This worksheet for testing change is nothing more than the model for improvement pushed out onto a piece of paper to help you document your quality improvement effort and to help you become that learning organization.
So here's your next steps. Review the coding for the MDS items for this quality measure for your residents who are triggering. Read that Quality Measure User Manual Specification again and let that help drive you in your root cause analysis. And then begin your quality improvement project to decrease inappropriate catheter use.
Feel free to check out our website for tools and resources. And we hope that in the future you'll use more of the quality measure video series to help you and your staff learn more about the quality measures and to help you through your quality improvement efforts. Feel free to reach out to us and let us know how we can help you and we'll be excited to hear of your successes.