Welcome to this session of the Quality Measures, The Prevalence of Behavior Symptoms Affecting Others. I'm Melody Malone of Quality Improvement Consultant with TMF Health Quality Institute, and I'm happy to bring you this program today. Our objectives are to review the quality measure specifications for the Quality Measure Prevalence of Behavior Symptoms Affecting Others Long Stay.
And we're going to identify the relationship between the Minimum Data Set, or the MDS items, and this Quality Measure. But here's my disclaimer. I am not an MDS expert. I'm going to encourage you to always use the RIA manual or the Resident Assessment Instrument User Manual, the Quality Measure User Manual, the Quality Measure ID Reporting Module, and the Five Star Quality Rating System Technical User's Guide.
You can locate all of these resources on the cms.gov website, as well as the TMF website. I'm going to also encourage you to use our wonderful Texas MDS program staff. They include Brian Johnson, the MDS automation and keys coordinator, and Cheryl Shiffer, the MDS clinical coordinator. So let's start talking about how is this quality measure used, behavior symptoms affecting others?
Well, it is not one of the quality measures that is reported on the state public website, the Texas Quality Reporting System, or you may know it as the QRS site. It is not part of the quality measures that go into the Five Star Quality Rating System on the CMS Nursing Home Compare website, but you will see it listed on the website. But it is not part of that calculation, nor is it part of the National Nursing Home Quality Care Collaborative Quality Composite Measure Score.
It is on your CASPER Quality Measure Report, and of course it will be used as part of this survey process. But it should really be used by you to help you identify what might be a problem, to help you search for correlations in the quality measures, and to help you understand the impact of a single click on your MDS. And also how the world views you.
But keep in mind this is all retrospective. You need to use your quality measure reports to help you launch your quality improvement efforts and collect concurrent data as you work through your quality improvement process so you can ensure that you are making progress. So let's start talking about this quality measure, prevalence of behavior symptoms affecting others.
This is a long stay quality measure, which means the cumulative days in facility are equal to or greater than 101 days. Now, this issue of long stay and short stay quality measures, those are mutually exclusive. So on any given quality measure report, a resident is only a long stay resident or a short stay resident, but not both. So in this case, long stay, cumulative days in facility, 101 days or more.
When you look at your facility level quality measure report, you will find this measure reported, behavior symptoms affecting others L means long stay. In this case, for our facility today the numerator is 8 out of a denominator of 68. So eight residents triggered as having behavior symptoms affecting others out of a denominator of 68, all of those it could've triggered for a facility percent at 11.8. And you'll notice there is no adjustment in this quality measure.
Again, the state average and the national average, and this facility is performing much better than the state and national average, and they are in the top 22 percentile in the nation. So they're performing in a highway in that they're in the top 22%. Remember, for the quality measures, getting closer to 0 in the numerator is an indicator of potentially better care.
So in order to analyze this, you need to go to your quality measure user manual, look at those measure specifications, then go to your RIA manual, or the MDS manual to help you identify whether or not you're coding it accurately. Once you know that, then you can determine do you have a quality improvement opportunity? So, let's talk about this word, prevalence. You've heard that several times already.
So the Merriam-Webster online dictionary defines prevalence as the percentage of a population that is affected with a particular disease at a given time. But Mosby's Medical Dictionary defines it a little, I think, more clearly for us. The number of all new and old cases of the disease, or occurrence behavior symptoms affecting others of an event during a particular period.
So keeping that in mind, let's go to our quality measure user manual, look at these measure specifications, and figure out how to, for this measure, report the percentage of long stay residents who have behavior symptoms that affect others during the target period. So keeping in mind long stay, looking at our numerator, we know this means that our residents have total days in facility, 101 days or more with a selected target assessment where any of the following five conditions are true.
So on the MDS, the resident is coded a 1, 2, or 3 as having the presence of physical behavior symptoms directed toward others at E0200A, or the presence of verbal behavior symptoms directed toward others at E0200B, or the presence of other behavioral symptoms not directed toward others at E0200C, or rejection of care at E0800, or wandering at E0900.
So if any one of these cases is coded a 1, 2, or 3 at any of these MDS items, even if 1, then the resident is now potentially in the numerator. But the denominator is all residents with the selected target assessment, except those with exclusions. So, the exclusion is that the resident is not in the numerator if any of the following is true.
So, the target assessment is a discharge assessment at A0300F, coded as a 10 or an 11, or any one of those five items above is missing, meaning they have a dash, indicating that the item with not assessed, or a carrot, meaning that the item was skipped.
But that would apply to each individual item, because remember, every one of these bought, physical symptoms directed toward others, behavioral, verbal behavioral symptoms affected toward other, behavioral symptoms not directed toward others, rejection of care or wandering. If any one of those is coded a 1, 2, or 3, and one of the others was not assessed or skipped, they will still be in the numerator.
So, in looking at our MDS items, let's look at these issues. So a 1, 2, or 3 is that the behavior occurred any one of those days during the observation period. So day one all the way through day three.
So if any one of these items, A, B, or C, physical behaviors directed toward others, verbal behavior symptoms directed toward others, or other behavioral symptoms not directed toward others, then they will be coded or triggered in the numerator if they don't have an exclusion all the way across the board.
Now, the other two items, rejection of care and wandering are the same, coded a 1, 2, or 3, meaning they occurred any one of the days of the observation period for rejection of care or wandering. I'm going to encourage you to read the MDS Mentor of December 2013 to reassess your understanding of the ARD and that observation period, because that's a great first step to ensure that we're coding our MDS accurately. You can find that on the DADS website.
Once you look at your facility quality measure report, and we did see that we had 11 residents with behavior symptoms affecting others, then you go to your resident level report and identify for the residents that are triggering, as denoted by the x, what else might be going on. So in this case resident A1 also has an anti-psychotic med long stay and a fall.
Resident L1 also has an anti-psychotic med and a fall. So we might say, hm, we're starting to see some correlations here. Is it an anti-psychotic med, or the behavior is resulting in the fall? Is there a correlation between these three items for the rest of the 11? Then we may see that we've got a great quality improvement opportunity for this correlation, aside from just behavior symptoms affecting others.
Once you begin looking at that analysis, you do your root cause analysis to help you understand what's really going on, what's the fundamental reason that we're having this problem? Why we're not meeting that expectation, getting closer to zero in our quality measures. I would encourage you to look for errors on the MDS first. Do we have a point and click error, do we have an accuracy of coding error?
What's really the MDS problems? Do we have a problem with understanding our ARD? Once you've figured that out, then look at what's the real reason behind the behaviors. Think of behaviors as unmet needs. So when we're looking at these unmet needs, or communication of these unmet needs as behaviors, then we can identify maybe quality improvement opportunities we might have.
That leads us to our model for improvement. So what are we trying to accomplish? Decrease inappropriate behaviors, or communication as unmet needs. How will we know that a change is an improvement? We need to measure our data. Remember earlier I mentioned concurrent data monitoring, so that's where that will come into play. What change can we make that will result in an improvement?
Depends upon your root cause analysis. What were your findings in your root cause? Then you're going to come up with a robust plan based upon what change you can make that will result in an improvement. Part of your plan is a measurement strategy so you can determine whether or not you're successful, then go out and do your plan, collect your data, study those results, and then act upon those results so you can get to a sustainable level of quality improvement.
The worksheet for testing change is a way for you to document your plan to use study act cycles, and to help you become a learning organization by noting what works, what doesn't work, and how you can learn to move your quality improvement process forward. So here's my challenge to you, your next steps.
Review the coding for these MDS items and this quality measure, and read that quality measure user manual specification so you can really understand how does this measure trigger in my building? Complete your root cause analysis and begin your quality improvement project, and check out our website for more tools and resources.
And we hope that you'll use all of the quality measure sessions to help you and your team learn more about your quality measures, more about your quality improvement process, so that you can raise your level of quality in your facility. We wish you the best of luck. Reach out to us and let us know how we can help you in your future quality improvement endeavors.