Welcome to this session, the Quality Measure-- Percent of Residents Who Made Improvements in Function 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.
The objectives are to review the quality measure specification for the percent of residents who made improvements in function short stay, and to identify the relationship between the minimum data set, MDS, and the quality measure. Here's my disclaimer. I am not an MDS expert. Always use the Resident Assessment Instrument User's Manual, the RAI, the MDS 3.0 Quality Measure User Manual, and the Five-Star Quality Rating System Technical User's Guide.
You can find those resources on the cms.gov website, and they are subject to change in location and manual content. We also have links on our website. So how is the short stay ADL improvement quality measure used? The Centers for Medicare and Medicaid Services, CMS, has it posted on the CASPER quality measure report. You will also find it on the CMS Nursing Home Compare website. It is a measure included in the Five-Star Quality Rating System. It is not one of the National Nursing Home Quality Care Collaborative Quality Composite Measure Score items at this time. It's December 2018 when I'm making this recording. It is included in the survey process in that the surveyor's software program has the MDS data and creates quality measures for them.
So when you do look at the Five-Star Quality Rating System, you can see that there is quite a few CASPER quality measure items that are included and percent of residents whose physical function improves from admission to discharge is one of them. But this [INAUDIBLE] needs to be used by you to help you identify what might be a problem in your facility, to help you search for correlations, to understand the impact of a single click, and appreciate how the world views you. But remember, that's all retrospective. So through quality improvement, we can begin working proactively.
So let's start by looking at the facility quality measure report. You will find this item at the very bottom of all of your items that are on this CASPER quality measure report, improvement in function, short stay. To analyze, you need to go to the Quality Measure User Manual, identify the measure specifications, then go to the RAI manual. Identify if coding is accurate. Perhaps there is a point and click error, or perhaps those who code the MDS don't really understand all the items and aspects that go into that MDS item. Or maybe they don't understand it in relationship to the assessment reference date or the ARD.
Then you can determine, do we have a quality improvement opportunity. So the percent of residents who made improvements function is a short stay measure. Short stay is defined as the cumulative days in facility are less than or equal to 100 days. There are short stay measures and long stay measures on any given report. They are mutually exclusive. A resident is either short stay or long stay for all of those measures on any given report.
So let's look at the Quality Measure User Manual and see how this manual defines this measure. So this measure reports the percentage of short stay residents who are discharged from the nursing home and gained more independence in transfers, locomotion, and walking during their episodes of care.
Now CMS has put a special note here. So it's important that we read this. "A valid preceding five-day assessment or admission assessment refers to the date of the earliest assessment if a resident has both a five-day and an admission assessment. A valid discharge assessment refers to a discharge assessment with a date closest to the valid proceedings five-day or admission where a return is not anticipated. And then the five-day or admission assessment should be used to calculate the [INAUDIBLE] cut off, the quality measure calculation." If a resident has both a five-day and an admission assessment. They calculate the covariate using the assessment with the earlier date. [INAUDIBLE] are recalculated in each quarter.
So the important thing to understand here is that if there is a five-day assessment and there is an admission assessment, the very first assessment, the earliest date is what's used in the entire calculation for the quality measure. So now let's go to the numerator. So the numerator is short stay residents who have a valid assessment, a valid discharge assessment, at A0310F as a 10, which again would mean return is not anticipated, and a valid preceding five-day assessment or admission assessment, and they have a change in performance score that is negative, meaning the valid discharge assessment minus the valid preceding five-day admission or admissions.
Performance is calculated as the sum of these items in section G-- transfer self-performance, locomotion on the unit self-performance, and walking corridor self-performance. With 7's in those items, meaning the activity occurred only once or twice, and 8's, meaning the activity did not occur, those are recoded to 4's for total dependence for the purposes of the measure of calculation.
So it's important that we understand this is section G items, transfer self-performance, locomotion on the unit self-performance, and walk in corridor self-performance. So the denominator is going to include short stay residents who meet all of the following conditions, except those with exclusions. So have a valid discharge assessment at A0310F is a 10, again, where return is not anticipated, and they have a valid preceding five-day assessment or admission assessment. And again, whatever is earlier, is going to be used.
So let's look at the exclusions. So when there is an exclusion, the resident is no longer in the denominator, and therefore, they cannot trigger in the numerator. So residents that satisfy any of the following conditions, they have comatose marked in section B, 0, 100 on the five-day or the admission assessment, whichever one is used in the quality measure calculation. They have a life expectancy of less than six months at J 1,400, again, on the five-day or admission assessment, whichever is used. They have hospice at O0100k2 on the five-day or admission, whichever is used in the quality measure calculation.
If the resident has missing data on any of the assessments used to calculate the quality measure, so that would mean the discharge assessment and the five-day or admission, whichever one is used, the resident is then excluded if those section G items are missing. We don't want that exclusion. We don't want missing data on our MDS's. Thorough, complete, accurate MDS's are our best friend.
If the resident has no impairment rating for these three items on the five-day or the admission, then they are excluded. They can't get better than independent. So they're a 0. In all three items, they are excluded. Residents that have an unplanned discharge on any assessment during the care episode as noted in MDS item A0310G is a 2. They are excluded. So that's your only discharge exclusion.
Now let's look at the MDS items themselves. So is pulling from the section G items of transfers, walking corridor, and locomotion on the unit. And all three of these are coming out of the number one column of self-performance. You may have noticed on the quality measure specification page the covariates on the right column. A covariate is found to increase the risk of an outcome. There are only five of the quality measures that are risk-adjusted using the resident level covariates.
This measure, percent of residents made improvements in function short stay is one of those. I'm not going to go through explaining all of the covariates. But again, I think what's important to understand is thorough and accurate MDS's every time are going to make the difference in how your quality measure is calculated accurately, so you are reflected positively for the care you're delivering at the bedside.
So let's look, again, at the facility quality measure report, because this one is opposite of all the rest of the measures that you have. This measures actually risk-adjusted, so that's remember, one of five. So when you look at your quality measure report you want to look in the facility risk-adjusted percent column. And you will see that risk adjustment. But what also is unique about this measure is it's reported positively.
Listen to how it sounds. Residents who made improvements in function short stay sounds like a good thing, right? Two thumbs up. We would want all of our short stay residents to make improvements. So there's a special note on the quality measure report to help you understand that the comparison group national percentile works in reverse for this measure, because for the improvement in function short stay measure, a single asterisk indicates a percentile of 25 or less, where higher percentile values are better.
So the way to think about this is you want 100% of your residents that qualify to be in the denominator to also be in the numerator. So your facility observed percent and your facility adjusted present are 100%. And then your comparison group national percentile will also be high at 99 or 100. I've seen it both ways. So this one works opposite, so you've got to kind of wrap your brain around that one.
So the way to look at this is when you subtract 3 in the numerator from 4 in the denominator, you have one missing resident. So we have one resident who did not improve in function short stay. So that one resident is our quality improvement opportunity.
But here's your challenge. This only triggers when the resident is discharged. So at that point, everything's been done. You will only find the residents in this measure that actually trigger for the measure, meaning they did improve in function. So if I had all the pages of this report for the discharge up here, we would be able to count three. We would not find four. We would not find that missing resident.
So you find this only once the resident's been discharged. It's in this final column over here of all the measures right before the quality measure count, and I've highlighted for you, so we can see our two residents out of the three that we can see on this page who made improvements in function.
So in order to work on the quality improvement, we have to think about where does all of this begin. And it really begins at our bedside care. So accurate MDS's coming into the facility with that very first MDS, whether it's a five-day or an admission, excellent bedside care, driving that resident to make improved function. So when we do a discharge MDS, discharge return not anticipated, then when that calculation is made, we will see reflected in our quality measures the 100% in improvement that we would want.
Now, keep in mind the way that this works, great bedside care, good MDS's, good quality measures. Those measures that do go into the composite score then are going to be accurate, and your composite score should get lower, and then, eventually, we see the quality measures also reflected in the five-star rating. So the composite score does not create the five-star rating, but all the quality measures, it's all the same quality measures. It's just tiny.
We do have for you a root cause analysis tool for this measure. When you are logged into our website at tmfqin.org, you will find it when you click on the blue box, Resources for Activities of Daily Living. You'll be able to find it in the list. Now, when you go to look, it may not be up the very tip top. But you'll find it in the list. It's an Excel spreadsheet. And you can download that Excel spreadsheet. And then you can use it to proactively work on who are your residents right now in your building, and how are they performing, how did they perform on their first MDS, how are they doing today, what would we anticipate at discharge, will they show that positive improvement.
And if not, you have that opportunity right now to figure out what the gap is, why are they not making those improvements. On this spreadsheet, at the bottom, if you're familiar with Excel, you'll see there's a blank worksheet, there's an example where the resident met criteria, an example where they did not meet criteria, one with an admission exclusion, and one with the discharge unplanned exclusion.
So these are all tabs. Once you download the file, you can just click. And then you can actually work the measure proactively, because going back and trying to find that one resident that did not make improvements is sort of like looking for a needle in a haystack. So working proactively with this measure is absolutely the best strategy. But if you can find that resident or those residents that have not improved, then you could look at doing a complete root cause analysis to identify why did we not meet the performance expectations, which would be 100% of our residents, who discharge return not anticipated, actually improved in function.
Once you do the root cause analysis, then you move to the model for improvement, and we always ask three questions. What are we trying to accomplish? Ensure that all of our residents short stay that are discharging, return not anticipated, improve in function. How will we know that a change is an improvement? We're going to track our data. We can look at our quality measure, but we really need to track internally. That's why you have that Excel spreadsheet that can help you proactively.
But from your root cause analysis, you can identify what change can we make that will result in an improvement. And once you do that, then you can build your plan, do, study, act cycle around that test of change that you're going to run in order to improve this measure.
Once you do that, I highly recommend that you document your activities on the worksheet for testing change. You can find this in our two QAPI resources in those blue boxes on our website. I encourage you to document all of your quality improvement efforts, the root cause analysis, and your plan, do, study, act cycle for quality improvement. I encourage you to write out your three questions, develop your robust plan for your quality improvement efforts, work your plan, and measure your results, and study them, and determine what do you need to do now in order to move this quality improvement project further.
So here's your next steps. Review the coding for the MDS for this quality measure. There's three different items involved as well as to ARB, that very first assessment, and the discharge, return on anticipated. Read the Quality Measure User Manual for this measure specification, so you really understand how this measure. Complete your root cause analysis and begin your quality improvement project. And you can always check out, again, the tools and resources on our website.
We've got lots of quality measure sessions for you. They're all designed to work together in the entire series. We hope that this will help your teams move through the process of quality measure review and quality improvement and support your efforts to train your staff in easy to learn short sessions. I invite you to join the quality measure, the TMF website at tmfqin.org. We provide technical assistance. There's a help email. I'll show it to you at the end. If you need help, we are here to help you and provide you that assistance to help you improve your quality at the bedside.
When you join the website, be sure you join the Nursing Home Quality Improvement Network. That will be part of what you do. And then you can contact us in nhnetwork@tmf.org, and we'll be more than happy to help you in your quality improvement efforts. Thank you.