Welcome to this session on the quality measures. This session is going to cover the percent of residents who were physically restrained. My name is Melody Malone. I'm a quality improvement consultant with TMS Health Quality Institute, and I'm happy to present this program to you today. So our objectives are going to be to review the quality measure specification, for the percent of residents who were physically restrained, this is a long stay quality measure. And we're going to identify the relationship between the MDS and the quality measure specifications. The MDS is the minimum data set.
But here's my disclaimer, I am not an MDS expert. I'm going to encourage you to always all your resources and tools available, that includes the resident assessment instrument user's manual, or the REI manual, sometimes I call it the MDS manual. The MDS 3.0 quality measure user manual, I abbreviate that a lot of time to the QM manual. The quality measure ID number reporting module, this tells you everywhere that the quality measures are used at the federal level, and the five star quality rating system technical user's guide.
In addition, you can get all of these website off of our website, the MDS website, or you go to the CMS website directly. You can also use the wonderful Texas MDS program staff that we have. You have Brian Johnson, who manages the MDS automation, and he's the QIES coordinator. Or Cheryl Shifer, who is our MDS clinical coordinator. And I really encourage you to reach out to those people. Their information is also on the quality measure video page.
So, let's jump into how is the quality measure for restraints used? Well it is used in every area that we have public reporting. You're going to see it on the Texas Quality Reporting System website as part of the QRS score. It is also going to be on your Casper quality measure report from CMS. It is on the nursing home compare website, which is the federal public website. So it's on both the federal and the state public reporting system, and utilized in the quality measure score in the five star quality rating system.
It is also one of the national nursing home quality care collaborative quality composite measure score. It is one of the 13 measures used in that, I'm going to show you in a minute, and of course it's used in the survey process. Surveyors are going to look not only that your residents who are restrained, but those were on the quality measure.
The five star quality rating system utilizes 9 quality measures to do the public website calculation for the five star quality measures. And it is also one of the 13 long stay quality measures that is part of the composite score. But really this needs to be utilized by you to help you identify what might be a problem, to help you search for correlations, to help you understand the impact of a single click. And also to help you appreciate how the world views you. But keep in mind, this is all retrospective review. We'll talk about quality improvement in a minute.
So this quality measure, percent of residents who are physically restrained, is a long stay quality measure, which means the cumulative days in facility is greater than or equal to 101 days. , Now this issue of long stay and short stay, are mutually exclusive. So on any given report a resident is only going to be considered a long stay resident or a short stay resident, not both.
When you look at your quality measure report, you can see this one-- you're just seeing a portion of the report-- so you can see the physical restraint quality measures. In our case today, our facility is at 0 which is awesome! Because 0 restraints is great for your residents, great for your quality measures, great for your public reporting. And their national percentile ranking Is also 0. Remember, most of these quality measures are written to the negative, so the closer to 0 the better. Good care at the bedside.
But in order to analyze for quality measures, let's say you're triggering in restraints, then in order to really analyze this, you have to go to your quality measure user manual, identify those measure specifications. Then go to the REI manual to help you identify if coding is accurate. You may find you have a point and click error, or you may find that those who are coding the MDS items may not be really understanding all specs of the items, or the ARD, the assessment referenced date.
Then you need to determine, do you really have a quality improvement opportunity? So let's look first at the quality measure user manual. So this quality measure physically restrained reports those residents, the percent of residents, of long stay residents, who were physically restrained on a daily basis. And that's an important feature, daily. So with long stay, when we're looking at the numerator, it's going to be based upon that long stay definition 101 dates are more, looking at that target assessment based on the date of your report.
So what is going to trigger in the numerator, is those residents who have a physical restraint. A trunk restraint used in bed is 2, which means daily. Limb restraint in bed is 2 Trunk restraint used in chair or out to bed is 2. Limb restraint used in chair or out of bed is 2, or chair prevents raising. In chair or out of bed is a 2. So in any one of these 5 circumstances, if the resident has this notice on their MDS as daily, then they will trigger in the numerator.
Those residents in the denominator are all long stay resident with a target assessment, except those with exclusion. And in this case our exclusions are pretty easy. It's that any or all of those items were not assessed or have a dash, meaning that it's missing non valid values.
So in the MDS Mentor, it discusses in chapter 2 for December 13th the item of the ARD. And by chapter 2 I meant in the MDS manual, chapter two, setting the ARD. I really encourage you to use your MDS Mentor to help support you in understanding the MDS, and how to code it accurately. And setting that ARD, as you know, is very critical.
But let's look specifically at this MDS definition of restraints. So if we're going to code it accurately on the MDS, we have to understand what a restraint is. And right out of the state operation's manual, appendix pp, and also in the RAI manual is the definition for restraints, and they matched perfectly. So restraint is any manual method, or physical, or mechanical device, material, or equipment attached, or adjacent to the residents body that the resident, the individual, cannot easily remove, and which restricts freedom of movement, or normal access to one's body.
So when you really understand that definition, it helps you identify and ensure that any device that you're using, material or equipment, does or does not meet the definition of a restraint. And that's the definition you all need to pay attention to. So as you're coding your MDS, so now we're looking at the MDS items, now you know whether or not that device or equipment or material is a physical restraint. So if it's code is used daily or 2, in any one of these five areas; trunk restraining or limb restrain in bed, trunk restraint limb restraint or chair prevents rising, in chair or out of bed, it will code out as a physical restraint for your resident, and you will see it on your quality measure report.
But notice, bed rail is not included in the quality measure, nor is other in used in bed, nor is other used in chair or out of bed. So, keep that in mind as you're looking at how you code your residents in restraints, or utilizing any devices. Ensure that you've got that definition accurately coded, and you'll notice the definition is right here in the MDS manual.
So when you're looking at your quality measure level report, this helps you identify which residents are being triggered for restraint. In our case, remember our facility with at 0, therefore we see no x in our resident list. So we're not going to see that. And you'll notice I've also highlighted for you to quality measure count. I think seeing that quality measure account can also help you prioritize your residence for quality improvement.
Once you identify if you do have a restraint problem, or if you have a quality measure problem. Let's say you have a restraint coding out on your quality measures, and you don't believe you have any restrained in your building. Well then you've got to do a root cause analysis, which helps you can understand and identify why that performance did not meet your expectation. So you expected to see 0 on your quality measure report, and you triggered a restraint. You have to do that root cause analysis and identify what really happened.
So, is this just an issue of a point and click error on the MDS? We meant to click one thing and we clicked something else? We meant to click 1 and we clicked 2. Or is it an accuracy for coding on the MDS? We did or did not understand the definition of a restraint, and therefore we coded it accurately or inaccurately. Or do we really have a restraint problem in our building? Do we really have an issue with restraints, and we need to identify, why do we have restraints? So any one, or all of these could be part of your problem, or your root cause.
Once you know that, we move on to the model for improvement and we identify what is it that we're trying to accomplish. Decrease inappropriate restraint use? Or increase accuracy coding of the MDS? Your root cause analysis will help you understand that. How will we know that it changes in improvement? We're going to collect data on all of our change efforts. And what change can we make that will result in an improvement? You're going to identify that out of your root cause analysis. Do we really have a restrain problem, do we have a coding accuracy problem?
And then you're going to do a very detailed plan to come up with the "Who's going to do what?" part of your improvement plan. Go do it, and measure your actions. Steady those measurements, and then decide an act, what are we going to do to actually make this quality improvement a sustainable improvement effort? Do we need to repeat a small cycle of plan to study act.
In your worksheet for testing change, this is nothing more than the model for improvement pushed out onto a piece of paper to help you document your quality improvement efforts. This is available for you in the QAPI resources on the DMS website.
So here's your next steps, review the coding for the MDS item for this quality measure, read your quality measure manual for your user specifications, complete your root cause analysis and begin your quality improvement project to reduce restraints, improve MDS accuracy. And then check out the TMF website for other tools and resources.
And we hope that you will use these quality measure series to help you improve your quality measures, improve your quality improvement efforts at the bedside, and help you support your staff in easy to learn, short training sessions. Feel free to reach out to us if we can help you in the future. Good luck!