Welcome to this session on the Quality Measures: The Percent of Residents Assessed and Appropriately Given the Seasonal Flu Vaccine. I'm Melody Malone, a Quality Improvement Consultant with TMF Health Quality Institute, and I'm happy to bring you this program today. Our objectives are to review this quality measure's specification.
Now this is the seasonal vaccine for flu (Long Stay). Percent of residents assessed and appropriately given this seasonal influenza vaccine (Long Stay). And then to help identify the relationship between the MDS items and the quality measure specification.
But here's my disclaimer-- I am not an MDS expert. I'm going to encourage you to always use the resident assessment instrument user manual, or the RAI, the quality measure user manual the quality measure ID reporting module, and the five-star quality rating system technical user's guide. You can access all of those resources on the cms.gov website, and also on the TMF website on the quality measure video page.
I also strongly encourage you to use the Texas MDS program staff. They're great and full of great information. Brian Johnson is the MDS automation and keys coordinator. And Cheryl Shiffer is the MDS clinical coordinator. Please reach out to them.
So let's talk about how this quality measure is used. And I'm going to whittle it down to just the flu vaccine. It is part of the Texas Quality Reporting System, or the QRS system, so you will see it reflected as part of that score. You will not find this measure on your CASPER quality measure report. So you will definitely have to keep your ongoing list of your residents who have or have not received the flu vaccine.
You do see this reported, however, on Nursing Home Compare, which is the federal public website. It is not part of the five-star quality rating system. There's only nine quality measures that go into that calculation. This one is not one of them. It is however, included in the National Nursing Home Quality Care Collaborative Quality Composite Measure Score. It's not directly included in the survey process, as it's not on your Test for Quality Measure Report, but of course the surveyors may choose to look at this at some point.
But because it's not on the Facility Level CASPER report, it is also not on the Resident Level CASPER report. So again, you'll have to make sure you keep your own internal tracking system. But as you review this Quality Composite Measure Score, you will see that this one is included as part of this composite score, comprising 13 long stay quality measures.
But really you need to be paying attention to this flu vaccine and whether or not it's a problem in your facility. So as you look through this measure, I want you to be thinking about your residents who do and do not get the flue vaccine. Are there correlations to other issues? And I want you to understand that even though you don't see this on your quality measure report, it is on your federal public website, it is part of your state public website calculation, and it's in the national nurse collaborative as well. So we want to make sure that we are paying attention, because the world does see you, and see all of this.
But keep in mind, any of this is retrospective. So your concurrent monitoring of your residents with the flu vaccine is important. So let's talk about how is this used. Well keep in mind this is a long stay quality measure, which means the cumulative days in facility equal to or greater than 101 days. Every long stay measure and short stay measure are mutually exclusive. So on any given report, a resident is only going to be reported as either long stay or short stay. But remember, you're not going to see this on your quality measure report.
But in order to analyze your data, you do need to go to the Quality Measure User Manual, identify those Measure Specifications, go to the RAI manual to help you identify if you're coding accurately, and then determine whether or not we have a quality improvement opportunity. But I caution you, there are four short stay influenza quality measures, and four long stay influenza quality measures noted in the quality measure user manual. So we're only going to be looking at one long stay quality measure.
And this is a real change. This quality measure is reported in a positive manner. So residents who do meet the criteria, it's considered positive. It's not negative as how most quality measures are written. So we want to ensure that 100% of our residents are assessed and appropriately given the flu vaccine.
So let's look at this measure. So this does report the percentage of long stay residents who are given appropriately the influenza vaccine during the current or most recent influenza season. So the numerator for this long stay measure is residents meeting any of the following criteria on the target assessment. So this means that they received the flu vaccine during the most recent influenza season or the current one. Whether they got it in the facility or outside the facility, as noted at MDS item O0250A and O0250C. Or the resident was offered and declined the influenza vaccine at O0250C, or the resident was ineligible due to contraindications at O0260C.
So in any one of these three circumstances they got the flu vaccine, in your nursing home or out of your nursing home, during the current or the most recent season. They were offered and declined, or they were ineligible due to medical contraindication, then they are considered having assessed and appropriately given the seasonal influenza vaccine. The denominator would be all long stay residents within that selected target assessment, except for those with exclusions. And the exclusion is that the resident was not in the facility during the current or most recent influenza season at O0250C.
So one coding tip out of the MDS manual at page O-7 says once the influenza vaccination has been administered to a resident for the current influenza season, this value is carried forward until the new influenza season begins. So again, back to your concurrent tracking of all of your residents, it'll be important to have a great tracking system so you can insure that you're carrying the value forward.
So keep in mind with all of these qualifications in the numerator, these are an "or" situation. So if the resident met any one of these three criteria, they're in the numerator, and therefore they're positively triggered for having assessed and appropriately given this influenza vaccine. And remember in your exclusion, the resident was not in the facility. If that is noted in O0250C as a one, then that resident is going to be excluded out of the denominator, which excludes them out of the numerator, and therefore they don't trigger in either case.
So let's look at this O0250. So in A, if it's a yes, and they did receive it in that facility, and you note is as an A, then you proceed on to the date that it was C. But remember, everything is included if they received it outside the facility, if they were not eligible, or they were offered and declined.
So those are the things that you want to keep in mind as you're moving forward, if someone's going to trigger positively. And remember, in the MDS mentor, to use these from the DADS website. And in December of 2011, they had an article reminding you, do not stop coding whether the resident received the influenza vaccine for this year's flu season until next year's flu season begins. So great reminder to keep that coding accurate.
Once you've done your tracking, and you've done your concurrent monitoring, and you've identified if all of your residents meet the current inclusion. Remember they got it in the facility or out of the facility during the current or most recent. They were assessed and declined, or offered and declined, or they were ineligible. Your only exclusion is they were not in the facility during the season.
So if you find that you have residents that we didn't even talk with, then that is an opportunity for us to do a root cause analysis, and to determine how did we miss people, giving them the flu vaccine? Because we know getting the flu vaccine is a huge opportunity for us. So is it just point and click errors on the MDS? Is it accuracy of coding? Are we not following through with carrying that value for their influenza forward to every MDS? Or is there a lack of vaccination. And I threw in here both residents and staff, because we know when staff are vaccinated as well, it helps protect those residents that were offered and declined. And are there any correlations to other quality measures, such as residents who returned to the hospital.
Once you've identified all of your root causes, then you can move on to your model for improvement. So what are we trying to accomplish? Increase the number of residents and staff who received the influenza vaccination. How do we know the changes in improvement? We're going to measure our data concurrently. We're going to track it concurrently.
What change can we make that results in an improvement? Depends upon what your findings were in the root cause. Was it and MDS coding issue? Are we not discussing it with all residents during the start of the season? What are we doing?
Then want change can we make that results in an improvement? Depends upon your root cause analysis. So then you're going to develop your robust plan, and include in that your measurement strategy so you can determine your success. Then go do your plan. Go work your plan and measure those results. Study those results. And then act upon them, so you can get to a point where you have sustainable quality improvement efforts.
You can utilize the worksheet for testing change. You can find that on our website. It's just the model for improvement pushed out onto a piece of paper to help you document your quality improvement efforts and to become a learning organization.
So here's my challenge to you. To review the coding for these MDS items and insure that you've got your coding accurate, and that you're carrying that value forward. And be sure to review the quality measure manual again to make sure that you fully understand the measure specification. Complete your root cause analysis, and begin your quality improvement project. And you can check out the TMF website for tools and resources.
And we hope that you will continue to use the quality measure sessions that we have for you to help you and your team learn more about these quality improvement opportunities that you will find in your quality measure. Feel free to reach out to us and let us know how we can help you.