Welcome to our session on Measuring Quality Improvement. I'm Melody Malone, a Quality Improvement Consultant with CMS Health Quality Institute. We're glad that you're joining us for this session. Measuring our progress is pretty natural. When we were kids, we measured our age, our weight, our months and weeks and days, our next birthday. We measured how many days before school ended or before school was starting, depending upon how well summer vacation was going. In healthcare, we take lots of measurements as well. We measure blood pressures, weights, sugars, wound size. We often do lots of counting like how many pressure ulcers we have in-house or how many falls we've had in the last month. But do we measure for quality improvement purposes? For us to know where to go in quality improvement, we have to start measuring and evaluating those measurements so let's take a look at measuring quality improvement. But before we begin, let's remember that as we measure quality improvement we strive to learn about our mistakes and errors, and we must never forget the potential human toll as a result of both clinical errors and errors in our business practices. Even though we will speak a lot about data in our quality improvement work, we must always remember each piece of data may acutely hurt a human being or has the potential to hurt someone. Every resident matters, every staff member matters, and every visitor and guest matters. So let's start looking at data and what should you measure? We collect lots of data, but using it to help us move quality forward is not typically something we've done well. We usually look at data once resident at a time. Data for quality improvement purposes has us look deeper into the data and what the data is telling us, and we've got tons of resources; we just have to use that data slightly differently. But part of what's important is we have to know what we're measuring. Quality Measure Reports like we did out of the Casper System and our Weekly Pressure Ulcer Reports both have data on residents with pressure ulcers, but they measure the question quite differently. One's current; one's based on MDS timing. Some residents on the Quality Measure Report could have pressure ulcers that healed several months ago. The Weekly Pressure Ulcer List may have residents who are not yet on the Quality Measure Report due to their short stay status. Without knowing the intricacies of how the data is collected, often called the "measure specifications," then you may not know what the data is really measuring and what part of the picture you are seeing. So let's talk about measure specifications a little bit. They usually include at a minimum the data source so it might be a check sheet that you keep, the MDS, the Weekly Pressure Ulcer Report; sources such as that. And then there's some sort of a definition and this defines who is included and who is excluded. For example; residents at the facility less than 30 days. Are they included or excluded? Or what about employees with the facility more than one year? Or is it all responsible parties? Are these folks in or out? That's what the definition should tell us. And then frequently you're going to see the numerator or the denominator. The numerator, kind of think of that as the number of people with the problem or whatever you're measuring. And the denominator would be all of those who could have the problem. And then the exclusions would be those are the folks you're not going to count; you've made a definition that says, "We're not including these for some reason." And then we should always have a time frame for the data so we know what time frame is really being represented. And then often times we'll have a benchmark. A benchmark serves as a standard of excellence in our achievement against which similar things must be measured or judged. You might use a state or a national benchmark. If you are part of a corporation, perhaps your company has established benchmarks. But keep in mind all records are meant to be broken so if there is a benchmark, it does not mean that your QI efforts might not produce a new high level of sustainable performance. That then becomes the new benchmark and how fun would that be if you became the new benchmark in your quality measure efforts? Pretty cool. So one of the reports that we have available to us is our Facility Quality Measure Report and this is just a brief example of what the report looks like but notice it has a time frame for the data -- the reporting period that I've highlighted -- and the numerator and the denominator so you can see that each measure has different denominators. That's driven by the full measure specification and who is included in the denominator and the numerator, as well as who is excluded. So as you develop your measure, you will have to determine this if you're not using something that's already established such as the measure specifications for the Casper Quality Measure Report which is a very well defined set of measure specifications. And then you don't want to just collect data; you have to determine how you're going to display your data. This is your opportunity to share your data with the world; with your team, with those in your facility, even with the surveyors so anybody can see your progress. And most of us are used to seeing graphs and charts today but without proper labels, you'll never know if a good thing is happening or not so all you know is something is going on from left to right. So let's add some labels and see what we have to say here. So we can see that we now have a title, so we know this is the "Texas Transfer Restaurants, Fractures, and Falls." You know that we now have a data source because this is the MDS Quality Measure Report from January of 2002 through October of 2010. You can see on the X axis or the horizontal axis at the bottom the entire data range for every data point and the color of the shapes and the squares help you to identify the different data streams that are being displayed. So you can see that blue is for "Falls" with the triangles, the little diamonds are the "Restraints" with the brown, and the pink is the "Fractures" with the squares. The legend on the left at the Y axis or the vertical axis displays values of the data being measured. In this case it represents the mean proportion of the population in the nursing homes in Texas with "Restraints, Falls or Fractures" for each quarter over the 8 years the data was captured. The only thing that's missing is the benchmarking data but in this case one, this graph is busy enough and two, this ultimately is the state data and has become a benchmark for our state. However, I'll tell you we're even better than this now. But the extra data labels where you can see the 7th scope effort begins or the towels to rug Medicaid conversion occurred help you to even understand more about what's going on with this data. So as you begin working with your data, it's ok if you're not a data expert. There are lots of people who can help you with that. The administrator or business office manager may be a great place to start. Someone in your corporation may be of help. You could call us at the QIO and see if we can help you with your data. Find some data to work with. You're already collecting a lot of information; create that graph, share it, and really decide then, "What can we do with the data; where do we want to go in our quality improvement efforts?" Because collecting data is not what we're all about; it's doing something with the data. But we can't manage it if we don't know what we're measuring so we want to always make sure that we're measuring the right things, displaying our data well, but using it for quality improvement and progressing our improvements down the road. Feel free to give us a call if we can help you out. Look forward to more in the series. Thank you.