Welcome to this quality measure video series, the quality measure on the percentage of residents who antianxiety or hypnotic medication long stay. I'm Melody Malone, a quality improvement consultant with TMF Health Quality Institute, and I'm happy to present this program to you today.
The objectives are to review the quality measure specifications for the percentage of residents who used antianxiety or hypnotic medication long stay and to identify the relationship between the Minimum Data Set or the MDS and the quality measure specifications. Here's my disclaimer-- I am not an MDS expert, so always use the Resident Assessment Instrument User's Manual, the RAI, or the MDS manual, the MDS 3.0 Quality Measure User Manual and the Five-Star Quality Rating System Technical User's Guide.
You can find all of those manuals on the CMS.gov website. They are subject to change in both location and manual content. We also have links to them on our website.
So how is this antianxiety or hypnotic percent quality measure used? The Centers for Medicare and Medicaid Services, CMS, has it on your CASPER Quality Measure Report. You will also see it posted on the CMS Nursing Home Compare website.
As of this recording in December of 2018, it is not in the Five-Star Quality Rating system, nor is it in the National Nursing Home Quality Care Collaborative Quality Composite Measure score. It is used in the survey process in that the surveyor software has the MDS data, and it creates quality measures for them.
But most importantly, it should be used by you to help you identify what might be a problem in your facility, to help you search for correlations between quality measures, to help you understand this impact of a single click on the MDS, and appreciate how the world views you. But this is all retrospective, so thorough quality improvement efforts, we'll be able to work proactively.
So let's start with the CASPER Quality Measure report, the facility-level report. I want to caution you, there are two antianxiety hypnotic measures. One is prevalence and one is percent. The one we're looking at today is the in N036.01CMS ID measure. I highly encourage you to always search the Quality Manual by CMS ID number so you will not get confused, especially with these two measures.
And if you'll notice, the numerator and denominator observed percent are much different. So these measures are obviously very different. So let's go and look at what this measure really means.
So this measure, the antianxiety or hypnotic medication measure, is a long stay measure. Long stay means that cumulative days in facility is greater than or equal to 101 days, and that includes discharges and readmits, but only days actually in the facility count. Measures are short stay or long stay, and a resident is only one or the other on any given quality measure report. They are mutually exclusive.
In order to analyze the quality measure, 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. You might have a point and click error, or perhaps those who are coding the MDS don't understand all aspects of the items and the Assessment Reference Date or the ARD. Then you can determine, do you have a quality improvement opportunity or not.
So this is the Quality Measure User Manual for this measure. And I want to point out the CMS ID number N036.01. So I searched it by CMS ID number to make sure I brought you to the percent of residents who used antianxiety or hypnotic medication long stay.
In the description, it reads this measure reports the prevalence of antianxiety or hypnotic medication use long stay during the target period. So let's look at the measure specifications beginning with the numerator or the residents who will trigger if they meet all the qualifications.
So the numerator is all long stay residents with a selected target assessment where any of the following conditions are true, and there is on or after before date issue here, so we're only going to look at the one where the target dates are on or after April 1st of 2012. So if the resident is noted in N0410b, antianxiety medication received for any day or number of days during the observation period or if they had hypnotic medication received at N0410d any day or number of days of the observation period. They could be in the numerator.
The denominator is the population being tested, so this is all long stay residents with a selected target assessment, except those with exclusions. So let's look at the exclusions, and again, we have the or after date of April 1st of 2012.
If there is missing data, which is what the dash means, at either of these two MDS items, N0410b or N0410d, the resident will be excluded. But we don't want missing data on our MDSs, so we really don't want that exclusion.
So let's look at the next one, which is the life expectancy of less than six months at j1400 is a 1 or hospice care while a resident, 00100k2, is a 1. So any of these exclusions will exclude the resident out of the denominator. Therefore, they cannot be there to trigger in the numerator. So that leaves that everybody else in.
Covariates. There are five quality measures that have a covariate or risk adjustment at the resident level. This measure does not have that, but I always want to make sure you're aware of these covariates, because at the end of the day, all MDS accuracy makes a difference. So MDS accuracy is your best friend.
So when we look at the MDS items, it's this page of in N0410 B for antianxiety, D for hypnotic, any day or number of days being used. And remember, this is medications by pharmacological classification.
So when we go to the resident-level quality measure report, you will find this measure. Again, be careful. This one is prevalent. They don't actually have the percents here, so it's not prevalent, so you know this is your percent measure.
You can see I've highlighted three residents-- B, D, and resident I-- that all are triggering for this quality measure. And I mentioned before you could look for correlations, so all three of them are correlating with behavior symptoms affecting others. Two are correlating also with falls. So as you're doing your quality improvement work, it might be interesting to look at these correlations and see if that might be quality improvement opportunity for you.
So good quality measures really begin at the bedside care. Great quality bedside care and documentation can result in very clear and concise MDSs, which create your quality measures. And then if the measure, which this one does not, goes into the composite score, it will create the composite score. And then lastly, if the measure goes into your five-star rating, it will create a five-star rating.
Now notice, the composite score doesn't create the five-star rating, but I want you to see it's all the same data. It just depends upon the time period and how the data is being used. So at the end of the day, it's all about quality care at the bedside first.
Once you've done your analysis and looking at that data and searching for correlations, I encourage you to search for the true root cause, the fundamental problem why we are having inappropriate use of antianxiety or hypnotic medication because that would be performance not meeting expectations.
So when you do your root cause analysis, you'll look at your data and look at all those correlations. Then come to your models for improvement and ask yourself, what are we trying to accomplish. Decrease the inappropriate use of antianxiety or hypnotic medication.
How will we know that a change is an improvement? We're going to track our data both on our quality measure report and your internal data, like your pharmacy reports. And what change can we make that will result in an improvement really depends upon what your findings are in your root cause analysis. When you do that root cause analysis, you'll identify opportunities that you can test in your model for improvement through the Plan, Do, Study, Act cycle for quality improvement.
We have a worksheet for testing change that you can use to document your quality improvement efforts. It's got the three questions, and then I encourage you to write a robust plan for that test that you're going to run.
Then go and do your test and document your results, including your data. Study those results, and then determine what are you going to do next. Do you need to modify the idea and retest, so you'll need to adapt it, or did it work great, so you just want to spread the idea and do a bigger tested change, or do you need to abandon this idea and come up with a new idea to test? Rarely do you actually have to abandon the idea, but if you ever do, be sure to document that quality improvement learning that you can also apply probably to other quality projects.
So here's your next steps-- review the coding for the MDS for these items. Read the Quality Measure User Manual measure specifications again. Make sure you really understand how these are triggering. Complete your root cause analysis and begin your quality improvement project, and you can check out our website for tools and resources at TMFQIN.org. On our website, when you go to the Nursing Home Quality Improvement home page, right now, you're going to find resources for reducing these medications also in reducing anti-psychotic medication use as well.
In future quality measures sessions, we hope that you will review them, work through the entire series, and that should help your teams learn the quality measure specifications and help you in your quality improvement efforts. We hope these support your efforts to train your staff in easy to learn short sessions.
I encourage you again to join our website. We're available to you for targeted technical assistance, and when you join the website, you'll have access to that Nursing Home Quality Improvement Network. There's lots of networks you can join, but the Nursing Home Quality Improvement Network is the one where you'll have access to those blue boxes. You just click on them, and they will give you all kinds of tools and resources. Just be sure to follow your company policy and procedure.
If you need any help, you're welcome to reach out to us. We have an email at nhnetwork@tmf.org. nhnetwork@tmf.org. And when you join the website, on the facing page for the Nursing Home Quality Improvement Network, that's there as well.
Feel free to reach out to us, and we wish you the best of luck in your quality improvement efforts. Thank you.