Welcome to this session on the Quality Measure, the percent of residents assessed and appropriately given the pneumonia vaccine. I'm Melody Malone, a quality improvement consultant with TMF Health Quality institute. And I'm happy to bring you this program today.
The objectives are to review the Quality Measure specification for this long stay measure, the percent of residents assessed and appropriately given the pneumococcal vaccine-- and I'm going to abbreviate this to pneumonia-- identify the relationship between the Minimum Data Set, the MDS, and the Quality Measure.
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 MDS 3.0 Quality Measure User Manual; the Quality Measure ID reporting module; and the Five-Star Quality Rating System Technical User's guide. You can find all those tools and resources on the cms.gov website, and also on the TMF website at the Quality Measure Video page.
I also encourage you to reach out to the Texas MDS program staff. They're great and have lots of information that they will share with you. Brian Johnson is the MDS automation and QIES coordinator. And Cheryl Shiffer is the MDS clinical coordinator. I encourage you to use them.
But let's get into how this measure, the percent of residents assessed and appropriately given the pneumococcal vaccination quality measure is used. It is on the Texas Quality Reporting System one of the measures utilized to calculate the score on the QRS, which is the state public website. You will not find this measure on your CASPER quality measure report, nor does it go into the Five-Star Quality Rating System that is on the Nursing Home Compare website that is part of the Five-Star calculation. You will see it on the federal public website, the Nursing Home Compare website, but it is not one of the nine quality measures that goes into the Five-Star Quality Rating.
It is one of the composite measure scores that's part of the National Nursing Home Quality Care Collaborative Quality Composite Measure Score. It is not formally in the survey process, in that it's not part of the quality measure report. But most likely, the surveyors will look to see the status of your residents.
So keep in mind because it's not on the CASPER quality measure report at either the facility level or the resident level, you will have to totally track your residents getting the pneumonia vaccine in your facility on your own.
Now I mentioned earlier the National Nursing Home Quality Care Collaborative Quality Composite Measure Score. There's 13 measures. And the pneumonia vaccine is one of them. But this needs to be used by you, so you can help identify what might be a problem in your facility, what might be correlations between your residents with pneumonia and other quality measures. It also helps you to understand the impact of a single click on your MDS, as well as how the world views you, because this measure is on both the state and the federal public website.
But all of that's retrospective data. You really need to use that to propel you in your quality improvement efforts so you can make progress and help prevent your residents from getting pneumonia.
As I mentioned earlier, this measure is a long stay quality measure. That means that cumulative days in facility is 101 days or more. Now, this issue of long stay and short stay are mutually exclusive, which means on any given report, a resident is only considered a long stay resident or a short stay resident based upon their cumulative days in facility. Long stay means 101 days or more in your facility.
In order to review this quality measure, you need to go to the Quality Measure User Manual, identify that measure specification, then go to the RAI manual so you can identify whether or not your coding on your MDS is accurate. Then you can determine whether or not you have a quality improvement opportunity. But I caution you, in the Quality Measure User Manual, you will find four short-stay pneumococcal quality measures and four long-stay quality measures for the pneumococcal vaccination. So be sure you're really clear and you're looking at the quality measure we're focused on today.
The other thing that's different is this quality measure would be reported, if it was reported, in a positive manner, because the residents who do meet criteria is considered positive, because we want everybody to get the pneumonia vaccine, right? So it's not negative, as most quality measures are written, because when we see someone triggering for a quality measure such as pain, we look at that as negative. No one wants to be in pain. Therefore, they triggered in that quality measure.
So let's look at this quality measure, the percent of residents assessed and appropriately given the pneumococcal vaccine, long stay. So this measure really measures, is their vaccine status up-to-date? And I think that's a really key ingredient here. So this is a long stay measure looking at residents meeting any of the following criteria on the selected assessment.
They have an up-to-date pneumococcal vaccine status at MDS item O0300A is a 1. They were offered and declined the vaccine at O0300B is a 2. Or they were ineligible due to medical contraindication at O0300B as a 1. So in any one of these cases, the resident is in the numerator, meaning they trigger for this, meaning they were assessed and appropriately given the pneumococcal vaccine.
The denominator is going to be all long stay residents with a selected target assessment. But this is an interesting quality measure, because it's the one quality measure with no exclusions. So every resident is counted in this long stay measure once they meet the long stay criteria.
So let's look at this MDS item, because there's lots of inclusions. So the first one is, is the resident's pneumococcal vaccination up-to-date, yes or no? If it is a 1 or a yes, they're included. The other inclusions are they were offered and declined, or they were not eligible due to medical contraindication.
Now, remember this talks about that their pneumococcal vaccination is up-to-date. Well, in the MDS RAI manual on page O-11, you will see this figure that is the CDC recommendations for how someone is determined whether or not their vaccination is up-to-date. So the real issue is, was the person vaccinated before they were 65 or after they're 65, and are they immunocompromised?
So if they're immunocompromised or if they were vaccinated before 65, then there's a decision that has to be made about has 5 years elapsed since their first dose, because if they're under 65 and 5 years or more have elapsed since their first does, then there is a one-time re-vaccination recommendation. And the same is true for immunocompromising conditions. So I encourage you to use this figure for every resident every time as you're going through that decision-making process for the MDS to determine is their vaccination up-to-date.
Once you've made that analysis and you've identified your residents that have not been appropriately vaccinated or their vaccinations are not up-to-date, then you want to search for the real root cause. How did we allow that occasion to happen? Because really, in our critical thinking state, we know that everybody vaccinated for the pneumonia protects them. So when at all possible, we would want 100% of our residents to be vaccinated.
So in searching for that real root cause, we have to determine, how did we miss it on this? How did we have a missed opportunity? So in searching for that root cause, I always encourage you to begin with your MDS. Do we have errors on the MDS? Is there a point-and-click error? Or do we have accuracy of coding issues?
And once you determine that, then we've got to figure out, so what's the reason for the lack of vaccination of the resident, because we know we want 100%. And then, are there any correlations to other quality measures or other issues, like readmissions, weight loss, decline in ADLS? There could be correlations that people with pneumonia have other problems and therefore it could help spur on our quality improvement efforts to help us solve our problem.
Which brings us to the model for improvement. This is our quality improvement methodology. So what are we trying to accomplish? Ensure every resident qualified has a current pneumococcal vaccination.
How will we know that a change is an improvement? Well, we talked earlier, you're going to have to collect your data concurrently. So we're going to be using data to determine whether or not a change is an improvement. And then what chance can we make that will result in an improvement depends upon the results of your root cause analysis.
Once you know what you're going to be testing as a change item, then you develop your robust plan, including a measurement strategy. Then you go out and do your work, do your plan, and collect that data along the way so you can study those results and then determine how you're going to act and spread your quality improvement efforts and learn from those quality improvement efforts so you can get to a sustainable level of quality. Wouldn't it be great at 100% of your residents appropriately assessed and administered the pneumococcal vaccine?
This Worksheet for Testing Change is a way for you to document your quality improvement efforts. It's available on the TMF website, because you want to become a learning organization. And you do that through documenting your efforts and learning from those efforts.
So here's your next steps. I encourage you to review the coding for the MDS items again for this quality measure, to use that Quality Measure User Manual specification to help you drive your quality improvement efforts, to do your root cause analysis by identifying who have we missed in our vaccination process and how did that happen? Then begin your quality improvement project and utilize the TMF website for tools and resources.
And we hope that you'll use these quality measure series to help you and your staff learn more about the quality measures and to jumpstart your quality improvement efforts. Feel free to reach out and contact us if we can help you in the future.