Welcome to this session on the "Quality Measures, The Percentage of Residents with Pressure Ulcers that are New or Worsened." I'm Melody Malone, a quality improvement consultant with TMF Health Quality Institute, and I'm happy to bring you this program today.
We'll be reviewing this Quality Measure specification for this short-stay measure, percentage of residents of pressure ulcers that are new or worsened, and we'll identify the relationship between the minimum data set items and this quality of measure specification. But here's my disclaimer. I am not an MDS expert. I'm going to encourage you to always use the "MDS Assessment Instrument User's Manual," the "RAI Manual," the "MDS 3.0 Quality Measure User Manual." the "Quality Measure ID Reporting Module, as well as the "Five Star Quality Rating System Technical User's Guide."
You can find all of those resources on the TMF website as well as on the cms.gov website. Additionally, I'm going to encourage you to reach out to the Texas MDS program staff. We have Brian Johnson who is the MDS automation and chief coordinator as well as Cheryl Shiffer, who is the MDS clinical coordinator. I think you'll find they are great resources.
Now let's launch into how is this quality measure used, and this measure is used a lot. In the State public reporting system, the Texas Quality Reporting System, this quality measure is now utilized as part of that calculation. You will find the measure on the "CMS CASPER Quality Measure Report" as well as on Nursing Home Compare, the federal public website.
Additionally, this quality measure is utilized in the Five Star Quality Rating System and in the survey process. It is not used in the National Nursing Home Quality Care Collaborative Quality Composite Measure Score. Those are long-stay measures only.
When you look at the Five Star Quality Rating System, the quality of measure calculation for the five star utilizes nine quality measures. This measure, percent of residents, with new or worsened pressure ulcers is one of them. But really this needs to be utilized by you to help you identify what might be a problem in your nursing home. to help you search for correlations between the MDS items and to understand the impact of a single click on the MDS and to help you appreciate how the world views you. But remember all of this is retrospective data. So you're going to want to utilize concurrent data through your quality improvement efforts so that you can see your quality efforts in motion.
So let's jump into how is this measure used. Well, it is a short-stay quality measure. So short stay is defined as the cumulative days in facilities are less than or equal to 100 days. Now these are days in facilities. This is a mutually exclusive issue between short stay and long stay.
Long stay is 101 days or more in facility. So on any given quality measure report, a resident is only a short-stay resident or a long-stay resident for their quality measures based upon their cumulative days in facility. When you look at your "CASPER Quality Measure Report," you will find this quality measure item new/worsened pressure ulcers short stay as noted by the S. In this case today, this facility had 0 new and worsened pressure ulcer short stay.
Yay for them because closer to 0 is better, right? Anytime we have a quality measure triggering in the numerator indicates a potential missed opportunity for day care. The denominator is a 34 and our facility observed percent is 0. There is an adjustment in this facility called covariates or in this quality measure and we'll address that. But since they're at 0 now, they're at 0 in their adjustment.
And you can see how they rate against the state and national average and their national percentile ranking is at 0. So being at zero in the quality measures is a great thing. And I want you to note this report period. This is important as we start talking about the quality measure specifications.
To analyze this quality measure and all of them, you need to utilize the "Quality Measure Manual," identify that specific quality measure specification, then go to the "RAI Manual." Then we can determine do we really have a quality improvement opportunity.
So let's begin looking at this "Quality Measure User Manual" specification. This measure captures the percentage of short-stay residents, remember 100 days or less-- cumulative days in facility-- with a new or worsened pressure ulcer at a stage 2, 3, or 4.
In the numerator, we see that it identifies short-stay residents for which a look-back scan indicates one or more new or worsening states 2, 3, or 4 pressure ulcers. So before we go any further, let's look at what that means, that look-back score. Remember I said to note that report period on your quality measure report.
So from the target date, for each individual resident, the quality measure takes that target date, which is the ARD for all assessments except the discharge. Of the last assessment in that selected date range on your "Quality Measureable Report," and it looks back within that short stay of 100 days or less so that it includes all of the data from all the other assessments within a target date in that time frame.
So I know that sounds confusing, but here's how I want you to think about it. For any given MDS, if the resident is a short-stay resident, 100 days or less in your facility, this quality of measure is going to look back at all of those MDS's that were completed prior and use that to help with the calculation for this quality measure.
So it looks at any assessment in a look-back scan to identify, did the resident have a stage 2 in MDS item M0800A, and is it greater than 0, and is less than MDS item M0300B1, which is a stage 2 for pressure ulcers. So the M0800 items A, B, and C indicate the stage 2, 3, or 4 is greater than 0, and it is less than its associated items at M0300 B1, C1, or D1.
So let's look at this item of MDS 800 A, B, or C. Well, it is the new in pressure ulcer status worsening since the prior assessment, whether it's an OBRA assessment or a scheduled PPS or the last admission entry or reentry. So it's trying to identify were there are any pressure ulcers that were not present on those prior assessments or were at a lesser stage.
Now, this is two questions for each item. So was there a new stage 2, or was it at a lesser stage, or stage 3, or stage 4? So two questions for each item, new or worsening.
So the way you think about this is it's looking for on the current assessment that were there any prior assessments where the MDS items at M0300, the current number of unhealed pressure ulcers, at each of those stages 2, 3, or 4, were 0 or lesser staged and if on the target assessment, at M0800, the worsening in pressure ulcer status since the prior assessment is higher, higher number of pressure ulcers or higher in stage.
And remember in the "MDS Manual," it defines for us worsening, so a pressure ulcer worsening is a pressure ulcer that is progressed with deeper stage, deeper level of tissue damage, and therefore staged at a higher number using a numerical scale of 1 to 4, using the staging assessment system classifications assigned to each stage, starting at stage 1 and increasing in severity to stage 4 on an assessment as compared with the previous assessments.
And it goes on to continue. For the purposes of identifying the absence of a pressure ulcer, zero pressure ulcers is used when there is no skin breakdown or evidence of damage. And you can find this definition on page M-25 in your "MDS Manual."
So let's go back and look at this again. So it's pretty easy, right? On any look-back scan indicates a new or worsened pressure ulcer at state 2, 3, or 4.
Now, the denominator indicates all residents with one or more assessments that are eligible for the look-back scan except for those with exclusions. So let's look at the exclusions. The residents are excluded if none of the assessment that are included in the look-back scan has a usable response for MDS items M0800 A, B, or C, and this situation is identified as follows, and I know this seems busy, but let's walk through it together.
So the system is going to look to see if each assessment that is included in the look-back scan have any of the following responses. So the response to M0800A is usable if either of the following conditions are true and the same is true for each one. So if M0800 is less than M0300, then that item is usable.
So the option then also though is notice the caret at 1.1.2, 1.2.2, and 1.3.2 where it indicates using the caret that the item was skipped. And then this second exclusion is if all assessments that are eligible for the look-back scan are discarded and no usable assessments remain, then the resident is excluded from the numerator and the denominator.
So remember on the MDS, these missing, non-valid values, the dash indicates that the item was not assessed. The caret indicates that the item was skipped. So if we are accurately completing the MDS's, then not assessing or skipping items won't be an issue.
Now, you may have noticed on that quality measure page, there on the right-hand column, are covariates. Well, covariates are found to increase the risk of an outcome. There's only three quality measures that are adjusted at the resident level with a covariate. New and worsened pressure ulcers is one of those. So let's look on this right-hand side, and again, I know it looks very, very busy, but let's figure this out.
You'll notice in covariate number three, and you'll see it again in a minute that there are a bunch of items that are now excluded. Those were only four assessments with target dates before March 31, on or before, on 2012. I'm recording this in 2014, so we're just going to skip over those.
So remember a covariate means that there is a risk adjustment at the resident level, and you will see that on the facility quality measure report in the adjusted facility column. So a covariate what it means, 1, means that it is triggering, therefore, it will apply the risk adjustment to the resident.
So the first measure specification is the indicator requiring limited or more assistance in bed mobility, self performance, on the initial assessment. So the covariate will trigger or be a 1 if at the bed mobility self-performance item at G0110A1 is a 2, 3, 4, 7, or 8.
The covariate will not trigger if it is a 0, 1, or if there is a dash, and remember the dash indicates that the item was not assessed. The measure specification too for the covariate is the indicator of bowel incontinence at least occasionally on the initial assessment. So you're starting to see that that initial assessment is important.
So the covariate is a 1, meaning it will trigger or apply the risk adjustment to the resident if the MDS item H0400 is a 1, 2, or 3. It will not trigger the covariate if it is a 0, a 9 indicating that it was not rated, so the resident had an ostomy or did not have a bowel movement for the entire seven days of the observation period. It's a dash meaning that the item was skipped or a caret meaning it was skipped, or a dash means it was model set.
Covariate measure specification three, that the resident has a diagnosis of diabetes or peripheral vascular disease on the initial assessment. So if at MDS item I0900 it's checked indicating peripheral vascular disease or peripheral artery disease or if an MDS item I2900 is checked for diabetes, if either of those are true, then the resident will trigger with that covariate and therefore risk adjusted. It would be a 0 if either of those two diagnosing are not checked, or if there's a dash indicating it was not assessed. Now remember, the MDS items at I8000 do not trigger the covariate and actually for any of the quality measures, it will not trigger if there's a diagnosis indicated as part of the quality measurable.
The covariate measure specification number 4 is an indicator of Low Body Mass Index, or BMI based on height at MDS item K0200A and weight at MDS item K0200B on the initial assessment. So the covariate is a 1 or the resident will be risk adjusted. If the BMI is greater than or equal to 12 and less than or equal to 19. The covariate will be a 0, meaning the resident will not be risk adjusted if the BMI is greater than 19 and less than 40.
The covariate is missing if either of the MDS items height or weight are missing as indicated by a dash for not assessed or a 0 or if the BMI calculation is less than 12 or it's greater than 40. So let's discuss this BMI calculation. It is a hand calculation, and you can see more information in the MDS Manual at page K-5. But the calculation itself is the BMI equals weight times 703 divided by the height squared. And then that value is rounded up to one decimal. But remember for the covariate, it's the BMI based upon the height and weight of the resident on the initial assessment.
The covariate is missing if there is no initial assessment available. And remember a covariate 1 means that it is an adjusted quality measure. So now when you look at this quality measure, perhaps it's not quite so confusing. If we're accurately completing our MDS's and we have all of our item addressed, we're not missing anymore. We're not skipping any, the resident was assessed properly, then we should see that all of these items are going to trigger appropriately.
So let's look back at this facility report again, and now you can see this facility-adjusted percent here. This is the item or the measurement that you would see on your public website reporting for the federal public website at [INAUDIBLE] is that adjusted person.
I'm going to refer you to the "MDS Mentor" of March, 2013 looking at the Diagnosis section I Coding. It's a two-step process, and it's important that we understand that well and also to Section M, Skin Conditions in the "MDS Mentor," March 2012. I think it's important that everybody understand accurate coding of MDS, and I encourage you to use these mentors to help you.
You can find those on the dads website. When you're looking at your "Quality Measure Level Report" for your resident, you can find the new and worsened pressure ulcer and just if there was a resident triggering, we would see an x. Remember though, this facility did not have a resident trigger.
So if you see an x anywhere, you can use that and look at what other quality of measures does that resident have for their total quality measure count, and is there any correlation between those quality measures, and that can help you in your quality improvement efforts as well.
Which brings me to the root cause. If we were having residents triggering for new and worsened pressure ulcers, we definitely would want to find out why did our performance not meet the expectations, because we would not want to have residents developing new pressure ulcers or worse pressure ulcers. So we would want to do that real root cause and try to identify what the problem is.
Well, there's lots of potential problems, and I may not have captured them all. It could be just flat errors on the MDS such as just a point-and-click error. You meant to click 0 but you clicked a 1, or accuracy for the pressure ulcer status and staging, or maybe it wasn't a wound at all, it wasn't a pressure ulcer, it was some other type of wound, which may mean there might be an error or a missing diagnosis on the chart.
So it could be an issue on the chart, an issue on the MDS of accuracy. And what about those covariates. Were they properly coated on the initial MDS? Remember there's four of them really five MDS items, bed mobility self performance, bowel incontinence, diabetes or peripheral vascular disease, and then height and weight. So really six MDS items that we would want to ensure on the initial we're accurately coding.
Then, of course, do we have an issue between facility-acquired pressure ulcers, meaning we caused the pressure ulcer, versus community acquired pressure ulcer. And was that a pressure ulcer coming in the door that we knew was going to get worsened, or did that surprise us?
So does that lead us to care and treatment opportunities? Because this is a quality measure measuring two things, a new pressure ulcer or worsened pressure ulcer. So once we've done that root cause analysis, now we can figure out if we've got changes that we can make that will result in an improvement.
So what are we trying to accomplish? Decreased, new, or worsened pressure ulcers. How will we know that it changes in improvement? Remember I mentioned early on, we have to collect current data during our quality improvement efforts.
What change could we make that would result in improvement? Depends upon your findings and your root cause analysis. Then you'll do your Plan, Do, Study, Act Cycle of quality improvement. You'll create your robust plan for how are we going to do what when, and that needs to include your measurement strategy.
Then go out and do our plan and measure those results. Then study the results and determine our actions. This is just the model for improvement pushed out onto a piece of paper, and you can access the worksheet testing change in the QA PI resources on the nursing home network page.
So here's my challenge to you. Review the coding for the MDS items for this quality measure. There are a lot of them. Ensure that you understand the measure specifications. You may need to review the measure specifications again and complete your root cause analysis so you can determine why do you have new or worsened pressure ulcers.
Then check out the TMF website for more tools and resources. And I encourage you to use all the quality measure video series to help you and your team learn more about the quality measures to help you work on your quality improvement efforts. If you need any help, we're happy to help you. You can email us or call us, and check out our website for more tools and resources. Good luck.