Welcome to this session of the Quality Measures, the Percent of Residents who Self-report Moderate to Severe Pain, Short Stay. 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 the Quality Measure specification for this measure. The percent of residents who self-report moderate to severe pain, short stay. And we'll identify the relationship between the Minimum Data Set, or the MDS items, and the Quality Measure specification. But here's my disclaimer. I'm 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's Manual., the Quality Measure ID Reporting Module, as well as the Five Star Quality Rating System Technical Users Guide. You can find all of those resources on the cms.gov website, as well as the TMF website. I'm going to encourage you to also reach out the Texas MDS program staff. They're great and they can really help you. You have Brian Johnson, who is the MDS Automation and QIES Coordinator, as well as Cheryl Shiffer, our MDS Clinical Coordinator.
But let's start jumping into how is this quality measure used? How is this pain short stay measure used? You will see it reported on the Texas Quality Reporting System, the state public website. It is one of the quality measures utilized in their calculations. You will find it on the CMS CASPER Quality Measure Report, as well as on the CMS Nursing Home Compare site, so the federal public website. It is one of the quality measures that goes into the Five Star Quality Rating system, and, of course, it will be used in the survey process. It is not one of the quality measures in the National Nursing Home Quality Care Collaborative Quality Composite Measure Score. Those utilize only long stay quality measures.
When looking at the Five Star Quality Rating System, and trying to understand your star rating, there's nine quality measures that go into that calculation. This measure of the percent of residents who self-report moderate to severe pain, short stay, is one of those nine quality measures. But really, all of your quality measures, and this one, should 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 quality measures, and help you understand the impact of a single click on your MDS. Also, to appreciate how the world views you, because you are on both the federal and the state public website. But this is all retrospective data. So, as we talk about quality improvement efforts, you'll have to track your quality improvement efforts concurrently, because it will take a while for your quality measures to catch up to your quality improvement.
So let's jump into this measure a little bit more. So what does this issue of short stay really mean? Well, it means that cumulative days in facility are less than, or equal to, 100 days. So these are days in facility, 100 days or less. There are long stay measures and short stay measures. But on any given quality measure report, the resident is only reported as a short stay, or as a long stay resident. It's a mutually exclusive situation. So this is a short stay measure, 100 days or less, days in facility.
When you look at your CASPER Quality Measure Report, you will see this reported on that report as SR, meaning self-report, moderate to severe pain, and the S indicates short stay. And you'll see that we have four residents in the numerator, meaning we had four residents trigger for having self-reported moderate to severe pain, short stay. Out of a total denominator of 13, for facility observed percent of 30.8, which is quite a bit above the state and the national average, which puts them in the bottom 20% ranking, meaning they're 80th percentile, but in that worse 20% in the country. This measure does not have an adjusted percent.
Now we are talking about the short stay measure. But there is also a pain long stay measure. So keep in mind, we had 10 residents trigger long stay, four short stay, for a total of 14 residents. So just kind of tuck that away. We're going to use that a little bit later. But we're only talking short stay as we begin to analyze, why do we have four residents in pain, short stay? So we'll have to go to the Quality Measure User menu, and understand those measure specifications. Go to the RAI Manual to ensure if our coding is accurate. And then we can determine, do we have a quality improvement opportunity or not? Or what is our quality improvement?
So in looking at the quality measure specification, this measure captures the percent of short stay residents with at least one episode of moderate to severe pain, or horrible excruciating pain at any frequency, in the last five days. So that's going to become very important. So in looking at the numerator for this short stay measure, the numerator will include short stay residents equal to, or less than, 100 days in facility, with a selective target assessment, where the target assessment meets either, or both, of the following two conditions. So they could meet condition one, or they could meet condition two, or both of those.
So let's start with condition one. The resident reports daily pain, with at least one episode of moderate to severe pain. In order for that to be true, both of the following conditions must be met. So in the MDS item J0400, the resident reports almost constant, or frequent, pain, as indicated by a 1 or 2 for that item. And, at least one episode of moderate to severe pain in J0600 A, or J600 B. Condition two, now remember this is an and or situation. So they can have condition one, condition two, or both. So the resident reports very severe horrible pain at any frequency, at MDS item J0600 A, or 600 B, and or.
So the denominator, so who would be in the denominator? Our denominator is going to include all short stay residents, with a selected target assessment, except those with exclusions. So let's look at exclusions. If the resident is not included in the numerator, meaning that the resident did not meet the pain symptom condition for the numerator, and any of the following are true, then the resident would be excluded. So they will be excluded out of the denominator. Therefore they will not trigger the numerator.
So let's look at these exclusions. The pain assessment interview was not completed at J0200. Which meant it was coded as 0, a dash, or a caret. The dash means that the item was not assessed. The carrot means that the item was skipped. Or the pain presence item was not completed, at J0300, meaning it with 9, a dash or caret. The 9 indicates the resident was unable to answer the pain presence item.
Or the third exclusion, if the residents is with pain, or hurting, at any time in the last five days, J0300 is a 1, and any of the following is true. The pain present frequency item was not completed at J0400 9, a dash or a caret, not assessed or skipped. Neither the pain intensity items were completed at J0600 A or B. The 99 indicates that the reason was unable to answer. And again, the item was skipped or not assessed. And J600 B, again, unable to answer, skipped or not assessed. Or the numeric pain intensity item indicates no pain. So J0600 A is a 0. So these are the quality measure specifications.
Let's look at the MDS items that we've just been discussing. Remember, we have two conditions. So condition one, at pain frequency at J0400, in the last five days the resident reported almost constant or frequent pain, and on the pain intensity item, a J0600. On the numeric rating scale, they scored a 5, 6, 7, 8 or 9. Or, on the verbal descriptor scale, moderate or severe, as indicated by a 2 or 3 for item J0600 B.
Remember there's that second condition, so they could meet one, or both, conditions. So condition two pain frequency, at J0400, it must equal a 1, 2, 3 or 4. If there is a dash, or a blank, or a 9, all of those items are exclusions. Then at J0600 pain intensity, the resident scored a 10 at J0600 A, or a 4, meaning very severe horrible on the verbal descriptor scale.
So when you're looking at your Quality Measure Report, and you've identified these residents that are triggering from your facility report. So we knew that there were four, so we're just seeing a portion of the report, here. You can look and identify what resident is triggering for this moderate to severe pain, short stay. So we see resident G1 is triggering not only with pain, but also with anti psychotic medication, short stay. And resident L1 is coding with pain, short stay, as well as new and worsened pressure ulcers, short stay, and anti psychotic medication, short stay. So we do a correlation, because we have two residents with pain, short stay, and anti psychotic medication, short stay. So that would be something to think about.
But remember earlier, we talked about that there were 14 total. There were 10 long stay residents with pain. So when you start looking at that, you might see are there any other commonalities, any other correlations. So if your residents at pain short stay and long stay, have some of the same sort of quality measures, then that may be a correlation for us to look at our quality improvement efforts.
I want to jump back just a little bit, to this MDS definition of pain. I think it's very important that we understand this definition and accept it. So on page J7 in the MDS Manual, what you'll find it reads, any type of physical pain or discomfort, in any part of the body. It may be localized to one area, or be more generalized. It may be acute or chronic, continuous or intermittent, or occur at rest or with movement. Pain is very subjective. Pain is whatever the experiencing person says it is, and exists whenever he or she says it does.
In addition to the pain definition, I'm going to encourage you to go to the December 2013 MDS mentor. You can find that on the DADS website. In this mentor, there's an article that discusses setting the ARD, the assessment reference date. And I think it's critical that we revisit this, periodically, with all people, completing the MDS items, but especially note that this pain interview is a five day look back. So that's critical to ensure we have accuracy of coding.
Which brings us right to our root cause. So as we move into our quality improvement thinking, we want to identify why do we have any resident in pain? So we have to look at how is it that our performance isn't really meeting the expectations? Because nobody really wants to be in pain, right? So we want to search for that root cause. The great place to start is looking at your MDS, to ensure that we do not have errors in coding, either a point and click type of error. We meant to click one but we clicked two. Or that we have accuracy in all of our areas, all of the items that we're completing.
Then we can look at, so what's our real pain problem? Is that we have people who don't understand the definition of pain? Who have issues helping residents with pain? So we may have more of a intervention strategy, versus a prevention strategy. I don't know about you, but I'd rather you prevent my pain, not just intervene. And then, are there any other correlations to quality measures? So as you look at your Quality Measure Report, as you look at your root causes, this will help bring you to your Model for Improvement for Quality Improvement.
So what are we trying to accomplish? Decrease pain. How will we know that a change is an improvement? Remember I mentioned very early on, you'll have to track your data concurrently. So you'll have to do that so you can see are the changes that you're testing actually working? Then what change can we make that will result in an improvement? That's really going to depend upon what you find in your root cause analysis. And then you'll work through your plan, do, study, act, of Quality Improvement.
So this worksheet for testing change helps you write a very robust plan, that includes your measurement strategy. Then you go out and work your plan, see if you can do it and measure those results. Then study your results, and then decide how are you going to act upon these results? What changes are you going to make, working through tests of change, to get those changes to a sustainable level.
So here's my next steps for you. Review the coding for the MDS items for this Quality Measure and review the Quality Measure specifications again. Complete your root cause analysis, and begin your Quality Improvement project. Nobody wants to be in pain. Check out our website for more tools and resources for quality improvement and pain. And then review all the Quality Measure video series. We hope that you'll find these to be easy, quick, and help you and your staff learn about Quality Measures. And feel free to reach out to us and let us know how we can help you in your Quality Improvement effort.