Welcome to this session of the quality measures, percent of residents whose ability to move independently worsened long stay. My name is Melody Malone. I'm 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 whose ability to move independently worsened, long stay, and to identify the relationship between the minimum data set and the quality measure.
But here's my disclaimer. I am not an MDS expert. Always use the Resident Assessment Instrument user's manual, the RAI manual; the MDS 3.0 Quality Measure user's manual; and the Five-Star Quality Rating System Technical users' guide. You can find those resources on the cms.gov website. But notice, they are subject to change in both location and manual content.
So let's talk about how this mobility worsened measure is used. The Centers for Medicare and Medicaid Services, CMS, has this posted for us on our CASPER Quality Measure report. You will also find it on the CMS Nursing Home Compare website.
It is a measure that goes into the Five-Star Quality Rating System. It is not a measure in the National Nursing Home Quality Care Collaborative Quality Composite Measure score. It is used in the survey process, in that the surveyors have access to all of the MDS data and their software program creates quality measures for them.
In the Five-Star Quality Rating System, there are many measures, both long stay and short stay, that are used in the calculation and this measure. Percent of residents whose ability to move independently worsened is one of them.
But most importantly, this should be used by you to help you identify what might be a problem, to help you search for correlations, and to understand the impact of a single click on your MDS-- also to appreciate how the world views you. This is posted on the CMS Nursing Home Compare web site.
But all of this is retrospective. We want to be working proactively through our quality improvement efforts. So let's look at the Facility Quality Measure report and identify where this data is. When you look at the report, it's actually at the bottom of the report. It's the second item from the bottom-- move independently worsen long stay. And you can see there are 6 residents in the numerator out of 38 in the denominator.
So long stay, this is very important. A long-stay resident means that they have had cumulative days in facility equal to or greater than 101 days. A resident is either short stay or long stay on any given quality measure report. It is a mutually-exclusive situation. They can only be one or the other. So this one's going to be looking at those long-stay residents who've been with you at least 101 days or more.
To analyze your quality measure, you need to go to the quality measure user manual, identify the measure specifications, then go to the RAI manual and identify if your coding is accurate. Perhaps you have a point and click error. Or maybe those who code the MDS items don't fully understand all aspects of the item and the assessment reference date. Then you can determine, do we have a quality improvement opportunity?
So let's look at the quality measure specifications. This is right out of the quality measure user manual. So this measure reports the percent of long-stay residents who experience a decline in independence of locomotion during the target period.
Let's start with the numerator. The numerator is looking at long-stay residents with a selected target assessment and at least one qualifying prior assessment who have a decline in locomotion when comparing their target assessment-- think current assessment-- with the prior assessment.
So the decline is identified in two ways. First of all, they recode all of the values that were a 7 or an 8 for the MDS item G0110E1. They recode the 7 and the 8 to a 4.
Then they look at an increase of one or more points on the locomotion on the unit self performance item, which is the G0110E1 MDS item. So they're looking for a one or more point increase in the item between the target assessment and the prior assessment.
Those in the denominator are all long-stay residents who have a qualifying MDS target assessment and at least one qualifying prior assessment, except those with exclusions. So let's go look at what those exclusions include.
They include a resident who is comatose in section B0100 or if there is missing data on that item at the prior assessment. The dash indicates missing data. We don't like missing data on our MDSes, so that's not an exclusion that we want. But if the resident is in a coma, then we can take that exclusion.
If there is a prognosis less than six months on the prior assessment as indicated by either prognosis less than six months at J1400 or hospice use at O0100K2. If either of those are missing on the prior assessment or not a value of 1, then they are excluded. Again, we don't want missing data.
The next one is if the resident is totally dependent during locomotion on the prior assessment, then they are excluded. So total dependent is identified as a 4, 7, or 8 in the MDS item. If there's missing data on the locomotion item on the target or the prior MDS, again, we don't want missing data. If the prior assessment is a discharge with or without return anticipated, then the resident is excluded. If there is no prior assessment, the resident is excluded.
I want you to notice over here on the right, this column of covariates. We're going to discuss that in a minute. That is in your quality measure user manual. So before we discuss covariates, let's look at the actual MDS item.
So this is your item in section G, G0110E1, which is self-performance. So this is locomotion on the unit, how the resident moves between locations in his or her room and adjacent corridor on the same floor. If in wheelchair, self-sufficiency once in the chair. So how it's coded in item 1, self performance, is what will determine from prior to target MDS whether or not the resident triggers in the quality measure.
So I pointed out covariates in the quality measure manual. These are found to increase the risk of an outcome. There are only five quality measures that are adjusted at the resident level covariate. So this is one of the five. Understanding that there are covariates is important.
The actual calculation for covariate is quite complicated and this one includes a lot of covariates. So I'm not going to go through all the detail, but I want you to see if your MDSes are not thorough, complete, and accurate, it could hurt you, so to speak, in your quality measures and in representing you out to the public, because then the covariate would not be accurate, perhaps. So accurate MDSes are your best friend.
So again, looking at the facility Quality Measure report, the way you see this impact of the covariate is in the facility adjusted percent. So most quality measures-- in fact, all in our test for quality measure report but one, improvement in function-- we want closer to 0. We don't want our residents to have declines in ADLs.
So we don't want them to move independently-- worsen, right? We want them to be better. So we want this to be closer to 0. Instead of 6 residents, we'd like to have 5 residents. In this case, the risk adjustment actually went up. We had a negative risk adjustment.
That's a huge window for us to look at our quality improvement efforts and identify why did we have a negative risk adjustment, and yet we had 6 people who got worse? Because that means they didn't have a covariate. Somebody didn't have a covariate.
So looking at the resident-level Quality Measure report, you can identify those residents that are triggering in this quality measure-- move independently worsen, over here on the far right. I've highlighted it for you. When you identify your residents, you would also want to look and see, are there any correlations to any other measures where all the residents or some of the residents are triggering in the other measures? That's a great way to look at your quality improvement work.
You'd have to look at all 6 to identify that. Because what we want to do is identify, is there anything that we're missing at the bedside? And our bedside care and our bedside care documentation are what help drive that MDS accuracy. We want our MDSes very accurate, so then we can trust our quality measure data.
And then if that measure goes into the composite score-- and again, this one does not-- then we would have an accurate composite score. And then if it goes into 5-star rating, which it does go into the 5-star rating, then we would have an accurate 5-star rating. So I never want you to forget, it all begins at the bedside with the individual resident-- taking great care of that resident.
So if you identify that it is a measure you want to work on, then you would want to search for the root cause. Do that root cause analysis to identify when your performance did not meet your expectations. In order to do that, you have to look at the quality measure specifications. You have to understand that coding-- look to see if coding is accurate. And then back up and say, what did we miss at the bedside?
Once you've done your root cause analysis, you'll move into the model for improvement. In the model for improvement, what you're wanting to identify is how can we accomplish this project of decreasing our residents who are worsening in mobility? So what are we trying to accomplish? Improve our residents' mobility, or maybe it's early identification of declines.
How will we know that it changes an improvement? We're going to track our data. You're going to look at your quality measure data, as well as in the internal documentation and data that you have. What change can we make that results in an improvement? Well, we have to do our plan, do, study, act cycle for testing changes based upon what we identified in our root cause analysis.
So the change that you may make that can result in improvement might have to do with MDS coding. Or it might have to do with early warning signals from your staff that a resident is starting to have changes. It's all based upon your root cause analysis.
Then as you're running your plan, do study act cycles for quality improvement. I encourage you to document robustly your quality improvement activities. So on this worksheet for testing change, you can document your three questions, robustly write your plan, work your plan, and talk about how well it went, compare your data and study, and determine did this really work or not and where do you want to go from here in act?
Do you want to adapt this tested change? It sort of worked, but we need to tweak it. Do you want to just adopt it as is and spread the idea to a larger group? Or do you want to abandon the idea?
Rarely do we ever abandon an idea. When we do, be sure to document your lessons learned in that quality improvement project so you can apply that to the next project. So root cause analysis and plan, do, study, act cycle for quality improvement.
So your next steps are to review the coding for the MDS item for this quality measure, read the quality measure user manual specifications again so you really understand how this works. Then complete your root cause analysis based upon your residents who are currently triggering, or maybe even those that you know right now that might trigger for this decline. Begin the quality improvement project and check out the website for tools and resources at TMFQIN.org.
We have many quality measure sessions for you and more coming in the future, so each session is designed to work within the entire series to help you and your team move through the process of quality measure review and quality improvement. And we hope these will support your efforts to train in easy-to-learn short sessions. I encourage you to join our website, if you've not already. It's at TMFQIN.org.
We provide targeted technical assistance and help you in your quality improvement efforts through many activities in our learning and action networks. When you join the website at TMFQIN.org, I encourage you to join the Nursing Home Quality Improvement Network. That's where you'll find all the tools and resources to help you in your quality improvement efforts. All are welcome. Just make sure that you create your account and you join the Nursing Home Quality Improvement Network.
So join the website, join the Nursing Home Quality Improvement Network. And I recommend you agreed to email notifications. We push out new tools, resources, articles, videos all the time. And that way, you'll always be up to speed on what we're doing. And if you need to reach out to us, we'd love to help you. You can email us at nhnetwork@tmf.org. Happy to present this program to you and good luck in your quality improvement efforts.