Welcome to this session of the Quality Measure, The Percent of Low-risk Residents Who Lose Control of Their Bowel or Bladder. I'm Melody Malone, a Quality Improvement Consultant with TMF Health Quality institutes, and I'm happy to bring you this program today. So our objective is to review the Quality Measure specifications for this measure. The Percent of Low-risk Residents Who Lose Control of Their Bowel or Bladder Long Stay. And we'll identify the relationship between the minimum data set or the MDS and this quality measure.
But here's my disclaimer. I am not an MDS expert. I'm going to encourage you to always use all the tools and resources you have available. They include the Resident Assessment Instrument User Manual, or the RAI. Some times I call it the MDS manual. The MDS 3.0 Quality Measures User's Manual. The Quality Measure ID Reporting Module, and the Five-Star Quality Rating System Technical Users' Guide. In addition, you can find all of these resources on the TMF website, and the cms.gov website. We also have the Texas MDS Program Staff, Brian Johnson, who is the MDS Automation and QIES Coordinator, as well as Cheryl Shiffer, who is the MDS Clinical Coordinator.
So let's look at how is this Low Risk with Loss of Bowel or Bladder Control used? And I may abbreviate that to B and B. Well you will find this measure as part of your Texas Quality Reporting System. It is one of the measures that goes into your QRS score. You will find it listed on the CMS CASPER Quality Measure Report, as well as the CMS Nursing Home Compares Rate. That's the federal public website. It is not one of the nine quality measures that goes into your Five Star Quality Rating Systems. But it is one of the thirteen quality measures in the composite measure score, and it is part of the Nurse-- the Survey Process. And when I mentioned the Composite Score of the National Nursing home Quality Care Collaborative, and it is one of those 13 long [INAUDIBLE], quality measures.
But this really needs to be used by you. Now, if you identify what might be a problem for your residents in your facility, now you search for correlations between the quality measures to help you understand the impact of a single click on your MDS, and appreciate how the world views you. But remember, all of this is retrospective. So you're going to have to use concurrent data monitoring as you work through your quality improvement process to see how you are making improvements in your [INAUDIBLE].
I mentioned before that this is a Long stay quality measure. So the percent of low-risk residents who lose control of their bowel or bladder Long stay means that those with-- those residents who have cumulative days in facility equal to or greater than 101 days. So on any given quality measure report, this issue of Long stay or Short stay is mutually exclusive. That means on any given report, a resident is either Long stay or Short stay, but not both for that report.
So when you do look at your Facility Level Quality Measure Reports, you can find this listed as low-risk lose B and B control, L, which means Long stay. In this case, this facility has a numerator of 4, a denominator of 15, for a facility observe percent of 26.7. There is no adjustment for this quality measure. Against the state and the national average, that's higher than the facility percent, and that puts them in the 19th percentile ranking in the nation. Remember, for quality measure, getting closer to 0 the better. So they're in the top performance. So they're better than-- in the top 20, because they're in the top 19th percent. But they still do have four residents at low risk, so let's take a look at this.
To do that, you must go to the quality measurement user manual, identify the measure specifications for this measure, then go to the RAI manual to help you identify if you're coding on the MDS is accurate. And then you can determine, do we have a quality improvement opportunity, or what is our quality improvement opportunity? So let's do that, and let's go to the quality measure user manual, and look at how this measure report, the percent of Long stay residents who frequently lose control of their bowel and bladder.
So we know this is a Long stay measure with a target assessment for those residents that are Long stay that indicates frequently or always incontinent of bowel or bladder. Bladder is at MDS side of H0300, or bowel is it MDS item H0400. And in either case, if they are indicated as a 2 or a 3 on the MDS, they will trigger. Now, notice that or. So bladder or bowel are a 2 or a 3. So when we look at this MDS item, what we see is that a 2 is frequently incontinent, or a 3, always incontinent.
So whether the resident is urinary incontinence or has bowel incontinence at a 2 or a 3, then they potentially are going to trigger at low-risk for having bowel or bladder incontinence, because there's that or in there. Now, let's look at the denominator. The denominator is all Long stay residents with a selected target assessment, except those with exclusions. Well, OK, so let's look at what exclusions we have, and I know this list looks long. But we'll break it apart, and hopefully make sense of it.
So we know the first exclusion is a target assessment, is an initial assessment, or PPS five day or readmission [INAUDIBLE]. Well, that makes sense, because this is a Long stay measure. The next one is the resident is not in the numerator, so they don't have bowel or bladder at a 2 or 3. And either one of those has a dash, which is a missing non-valid value, indicating that the idea was not assessed.
The third exclusion, residents who have any of the following hybrid conditions. So this is where we get to really identify that issue with low-risk versus high-risk. So a resident is considered high-risk if they have any of these conditions. So severe cognitive impairment on the target assessment as indicated by MDS items C1,000 is a 3, and C0700 is a one. Or MDS items C0500 is less than or equal to 7. Or the resident is totally dependent in bed mobility, self-performance, transfer self-performance, or locomotion on the unit self-performance in MDS items at section G as denoted by a 4, 7, or 8.
So let me circle back around. So a resident who has any of the following conditions. So if they have severe cognitive impairment as indicated by those two MDS items together, or C0500, less than or equal to 7. Or any one of the three ADLs, bed mobility, transfer self-performance at a 4, 7, or 8. That's going to put the residents at a high-risk [INAUDIBLE], so that will exclude them.
Our next exclusion is a resident who doesn't qualify as high-risk, and both of the following two conditions are true for the assessments. So C0500 is a 99, keep that in your head. We'll find that in a minute. Or they have non-risk, non-valid values. So even if the item wasn't [INAUDIBLE] arrow or the dash. And at the item C0700 was not assessed or skipped, or item C1000 was not assessed or skipped. For item 5 of the exclusions, the resident doesn't qualify as high-risk if any the following conditions are true, which is the ADL items of that mobility transfer or locomotion self-performance are skipped-- I'm sorry, not assessed as noted by the dash. Or the resident is excluded if they are comatose, or if comatose status is missing by a dash is indicating they were nullified.
Alert, they are excluded. If they have an indwelling catheter, at MDS item H0100A, or that status is missing, as indicated it was not a [INAUDIBLE] target assessment, or the same thing for ostomy at MDS item H0100C. The resident has an ostomy, or that status is missing on the target assessment indicated by a dash that they were not assessed. So I know this looks really busy, but if you're accurately completing your MDSs, then these non-valid values of the resident wasn't assessed or the item was skipped won't really be a problem. So now, we just wiggle it down to that issue of high-risk conditions. So let's look at that a little bit more in detail.
So remember, any of this is true, then the resident is high-risk, therefore they are excluded. So if they have severe cognitive impairment on the target assessment as indicated by MDS items C1,000, cognitive skills for daily decision making is a 3, so severely impaired. And at MDS item C0700, short term memory is a problem, as indicated by a 1. So if that's true for both of those items, the resident is high-risk, and therefore excluded. Or if on their BIMS that we interviewed for mental status, it is less than or equal to 7 or has a 99. Remember, if they are unable to complete one or more of the questions in the interview, then that's going to cause the resident to be excluded.
And remember, the other major group of exclusions are the ADLs as totally dependent at 4 or 7 or 8 in self-performance at bed mobility, or transfers, or locomotion on the unit. So if any one of those three is true, then the resident is excluded. And then there's additional exclusions, so any of those five criteria for high-risk conditions, if we have missing elements, if the resident's in a coma or it's missing, has a catheter or it's missing, has an ostomy or it's missing.
So that probably breaks it down. Makes it a little bit more manageable. And remember, I'm going to always refer you to the MDS mentor for setting the ARD discussion in the December '13 addition. You can find that on the dads website. So when we're thinking about do we have a MDS coding problem, ensuring that we have accuracy of the ARD is critical. Once you've looked at everything, you can look at your quality measure level report and identify for your residents, triggering with the catheter, are there other correlations to quality measure?
So in this case, resident G1 also triggers for anxiety or hypnotic medication use, Long stay, and has anti-psychotic medication, Long stay, as well. And the resident J1 also triggered for anti-psychotic medication, Long stay, and fall. So we do see a correlation in that both residents on this page with lots of bowel and bladder control also are on an anti-psychotic medication. So we would have to investigate and determine is there one leading to the other. Is there any correlation at all.
And that gets us to our root cause analysis, which help us-- helps us to understand, how do we even have this problem, and what is a system failure that's leading to this issue for our residents. When did that performance not meet expectations, or how does it not meet the expectations? So there could be many reasons for the potential [INAUDIBLE]. Do we have errors on the MDS? Back to that issue of is it a point clicker? We make them click a one, and we click the two or three or 99, and so the resident coded. Or is it accuracy of coding. Is it an issue with the ARD, or really understanding these items. If we find all of our coding is accurate, then we have to look at our reasons for our low-risk residents, and why do they have [? incontinence? ?] And what are the correlations of the other quality measures?
Once we do this root cause analysis, we can move to our Model for Improvement for quality improvement. So what are we trying to accomplish? Decrease low-risk residents with incontinence. How would we know that it changes in improvement? Well, we're going to collect concurrent data in order to measure those results. We will eventually see it pick up as we have our new MDSs cycling back around. What change can we make that will result in improvement? Depends upon our root cause analysis. Was it an MDS coding issue? Was it a true [? care-to-bedside ?] issue.
Then we come up with our robust plan to study acts cycle, and we have for you this worksheet which has been changed that you can complete and use it to help you document your quality improvement efforts, help you write that robust plan, and help you become a learning organization.
So here's my challenge to you as your next step. Review the coding again from the MDS items for this quality measure, as well as the measure specifications. Then complete your root cause analysis, and begin your quality improvement. Check out the TMF website for more tools and resources. And we hope that you'll use all of the quality measures there to help you and your team understand the quality measure specifications, and to help you improve your quality at the [? bedside. ?] Feel free to reach out to us if we can help you in any way.