Welcome to this recording of the quality measure prevalence of falls. I'm Melody Malone, a quality improvement consultant with TMF Health Quality Institute, and I'm happy to bring this program to you today. Our objective today is to review the quality measure specification for prevalence of falls, long-stay, and to identify the relationship between the minimum data set, or the MDS, and the quality measure, QM, specification.
But here's my disclaimer-- I am not an MDS expert. I'm going to encourage you to always use the tools and resources that you have available to you. At a minimum, those are the Resident Assessment Instrument User Manuals, the RAI manual-- I call it the MDS manual-- the MDS 3.0 quality measure user manual, the Quality Measure Identification Number by CMS Reporting Module, QMID and the Five-star Quality Rating System Technical Users' Guide.
You can find links to those resources on the TMS website, on the quality measure video page, and also directly on the CMS.gov website. Additionally, I'm going to encourage you to use the Texas MDS program staff for your questions. Brian Johnson can help you with MDS automation and key, and Cheryl Schiffer is our MDS clinical coordinator, and can help you with all things MDS.
So let's jump in to how is the fall quality measure used? Well the quality measure reporting system, or the Texas Quality Reporting System, became live in June of 2014, but the fall measure is not one of the quality measures utilized in that calculation.
Nor is it utilized in the Five Star Quality Rating System, that federal public website, nor is it used in the National Nursing Home Quality Care Collaborative Quality Composite Measure Score. However, you will see this quality measure on your CASPER Quality Measure Report. It is shown on the Nursing Home Compare site, and of course, the surveyors will use this from your quality measure report as part of their survey process.
But really, it needs to be used by you, to help you identify what might be a problem. To help you search for correlations in the quality measures, to help you understand the impact of a single click, and to help appreciate how the world views you. But remember, all of this is retrospective information.
What you do with it and how you make your quality improvement is what's going to really help you to improve care at the bedside. So let's jump into this prevalence of falls. Now this one is a little unique in that it is found in the quality measure user manual, towards the back in Appendix E.
It is a long stay quality measure, so cumulative days in facility means that it was equal to or greater than 101 days. And remember, the quality measures are mutually exclusive. So they're either a long stay measure or a short stay measure on any given report. They are not both.
The prevalence of falls. Prevalence is an interesting word, and I'm going to help you understand that. So I have two definitions. In the Merriam-Webster dictionary, it defines it as the percentage of a population that is affected with a particular disease at a given time. In our case, think falls.
Or in the Mosby Medical Dictionary, it's the number of all new and old cases of a disease or occurrence, of an event, during a particular period. I think that one really speak to our prevalence of falls measure. And I'm going to explain that to you in a little bit.
So when we look at the Quality Measure Report, we can find the falls quality measure. And remember, in the numerator, is the number of residents that triggered for the issue. So in our case, we have 36 resident, out of 75 who could have triggered. So at this point, if this is our facility, we're running above the state and national average. And we're in the 56th percentile ranking in the country.
Remember, closer to zero is better. Look, zero restraints. Zero new and worsened pressure ulcers. But 56 in falls. So opportunity for improvement, probably.
But in order to really analyze this, we need to go to the Quality Measure User's Manual, identify the measure specification, then go to the RAI manual and determine if our coding is accurate. Then we can decide if we have a quality improvement opportunity. So let's go to the Quality Measure User's Manual in Appendix E.
We will find prevalence of falls, long stay. So this measure and report the percentage of long stay residents who have a fall during their episode of care. That's important to understand, because this one's a little different because it picks up all long stay residents with one or more look back assessments-- we're going to discuss look back in a minute-- that indicate the occurrence of a fall in J-1800. It's a one.
So they had a fall at any time during that look back. The denominator is all long stay residents with one or more look back scan assessments, except those with exclusions. And in our case, the exclusion is true for all of the look back scan assessments, meaning the occurrence of falls was not assessed.
So, if on all the assessments for a given resident, it wasn't assessed, then that resident's excluded. so let's discuss this issue of look back scan. So from the target date, for all assessments except the discharge-- this is the ARD-- of the last assessment in the selected date range. Now remember that quality measure report has a date range that it looks at.
So based upon that date range, it looks at the last assessment, and then looks back 275 days, so that the quality measure includes all the data from the other assessments within that target date, in that time frame of 275 days. So this is a long look back.
Your MDS item-- don't confuse look back with ARD. So you're going to have your ARD for each individual assessment. But then the quality measure calculation utilizes this look back scan. So it's looking back at 275 days worth of MDS. And the ARD is discussed in the December 2013 MDS Mentor. And I really suggest you review that.
This chapter two refers to chapter two in the MDS manual. So don't get confused with ARD and the quality measure look back. ARD is on the MDS, quality measure look back scan for the calculation. So when you look at your quality measure level report for your residents who are triggering, you're going to see, with the x, those that trigger in the fall.
Now let's discuss the definition of a fall. When you look in the MDS manual, on page J-27, you get the definition of a fall, which is an unintentional-- and that's a key word. Unintentional change in position, coming to rest on the ground, floor, or onto the next lower surface. So for example, onto a bed, onto a chair or onto a bedside mat.
The fall may be witnessed, reported by the resident or an observer, or identified when a resident is found on the floor or ground. And the definition continues, falls include any fall, no matter whether it occurred at home, while out in the community, in an acute care hospital, or a nursing home. Falls are not a result of an overwhelming external force.
For example, a resident pushes another resident. And the definition continue to an intercepted fall, occurs when the resident would have fallen if he or she had not caught him or herself, or had not been intercepted by another person. That is still considered a fall. So there's a lot of characteristics in here.
Unintentional, occurred for any setting. And if it's intercepted, it's still considered a fall. So let's look at this MDS item. The MDS item J1800 is-- on each MDS, we're going to answer the question, has the resident had any fall since admission, entry, or reentry, or prior assessment, whether it's an OBRA or scheduled assessment, whichever is more recent?
If it's a one, then yes, they had a fall. So now we know whether our residents fell or not. We can look at our quality measure and realized, from the look back scan, that it's going to look at 275 days worth of MDSs to identify whether that long stay resident had a fall.
Now we know what we need to do is search for our root cause for our quality improvement efforts. So this is when you're really looking for the reason why this problem has occurred. Why has this fall occurred?
So there may be a lot of reasons for this root cause issue with falls. One may be that we have errors on the MDS. The resident never had a fall, and we just accidentally clicked two when we meant to click one. Or perhaps with an accuracy issue, like we weren't really capturing the correct ARD, or someone did not understand the definition of the fall.
And then, what is the fall problem? Is there a fall problem, and what is our prevention strategy for fall risk reduction, versus intervention after a fall has occurred? So all of this, and you may find more issues in your root cause analysis. So then when you go for your model for improvement, well, what are we trying to accomplish?
Is it MDS accuracy? Is it improving prevention of falls? Is it working on post-fall intervention? Based upon your root cause analysis, it will determine what are you trying to accomplish overall? Decrease falls, right? How we know the changes and improvement?
Well, we need to collect data. And this is a great example, in this quality measure, we're really tracking concurrent data as important in our quality improvement effort. Because we've got this long look back period. If we're really resting on the quality measures to help us track our improvements, it's not going to help us with this one very much. It takes a long time for that data to really make a change, to show a change.
So we've got to collect our concurrent data, and that's how we know the changes and improvement. Then what change can we make that results in improvement? Depends upon a root cause analysis. Then we need to develop our robust plan for what is it that we're going to do, who's going to do it, how are we going to do it? What's our measurement strategy?
Then we go out and do it, and collect our data, as well, along the way. Study those results, and then act on those results, and determine what are we going to do to improve this quality improvement issue long term? What efforts are we going to be able to put into place that will sustain decreased falls over an extended period of time?
You've got the worksheet for testing change. This is available in our QAPI resources. This is just the model for improvement pushed out onto a piece of paper so that you can document your quality improvement effort. And then, here's your challenge.
You need to go review the MDS item coding to ensure that you're accurately coding this item. Really understand the quality measure specification for this fall measure. Complete your root cause analysis, and begin a quality improvement project, because folks, we really need to change falls. We've got lots of people falling out there.
And then, check the TMF website for tools and resources. We hope that you'll use these quality measure sessions to help you in training your staff in these easy-to-learn short sessions to help you understand and move through your quality measure and your quality improvement process.
And we'll have all the entire series available for you soon. Feel free to call us if we can help you in any way. Good luck in your quality improvement efforts.