Welcome to this session of the quality measure video series, residents with a urinary tract infection. I'm Melody Malone, a quality improvement specialist with TMF Quality Innovation Network. And I'm happy to bring you to this program today. So our objectives are to review the quality measure specification for percent of residents with a urinary tract infection or UTI, long stay. And to identify the relationship between the minimum data set or the MDS and the quality measure.
But here's my disclaimer. I am not an MDS expert. I always encourage you to use Resident Assessment Instrument User's Manual-- or the RAI Manual-- the MDS 3.0 Quality Measure User Manual, the Five-Star Quality Rating System Technical User's Guide, and the CMS-- there's Medicare and Medicaid-- MDS video training. You can find all of those resources on the quality measure video series page on our website.
So how is the UTI quality measure used? Well, you're going to find it on your CMS CASPER Quality Measure Report. I'll show it to you in just a minute. It is on CMS Nursing Home Compare for the public to see. It is also a measure that is used in your Five-Star Quality Rating now. And the surveys use it in that they have access to all of your MDS data. And their system calculates quality measures for them to use during the survey.
But it really should be used by you. To help you identify what might be a problem in your facility, to help you search for correlations and understand the impact of a single click on your MDS and appreciate how the world views you. But keep in mind, this is all retrospective. It's after we've already done all of this.
So let's get into the measure specifications. So a percent of residents with a UTI is a long stay measure, which means the cumulative days in facility are equal to or less-- greater than 100 days. Cumulative days in facility includes discharges and readmit, but only days in the actual facility count. So long stay, 101 days or more in the facility. Remember, long stay and short stay are mutually exclusive. The resident is only one at any given moment on a quality measure report.
So speaking of the quality measure report, here's the facility level report. And when you go to look for UTI, it's a little bit further down on the page. And as you can see, for this facility, they had two residents in the numerator-- so two that triggered-- out of the denominator of 51-- all that could trigger. With a facility observed percent of 3.9%, there is no risk adjustment for this one. So you see that facility adjusted is the same at 3.9% against the state and the national average and the national percentile.
So in order to analyze this data and determine what's really going on, we need to go to the Quality Measure User Manual, understand and identify those measure specifications, then go to the RAI Manual to determine if our coding is accurate. Do we have just a point and click error? We meant to click no UTI and we clicked yes UTI. Or maybe we're coding things not accurately, according to the ARD or something else. Then, you've got that opportunity to determine, do we have a quality improvement opportunity?
So in looking at the Quality Measure User Manual for the measure specifications for this measure, again, it's reporting long stay residents who have a UTI. In the numerator is all long stay residents with a selected target assessment that indicates a UTI within the last 30 days. This measure is different. This MDS item is different. In the last 30 days.
Out of a denominator, which would be all long stay residents, with a selected targeted assessment, except those with exclusions. So exclusions would include if the target assessment is an admission assessment or a five day PPS or Medicare readmission return assessment. The other exclusion is if there's missing data in the MDS item I2300. That is never an exclusion we want.
So if we go to the resident level report, you'll find UTI listed there. And you can see on this one page, we can identify one out of the two residents who had a UTI. So now, what we need to do is determine, did we code it accurately? So in looking at the MDS, it's coded at MDS item I2300 UTI in the last 30 days.
So we need to look at the definition. You can find the definition in the RAI Manual, beginning on page I12. So this one, they give you a reminder. It has a look-back of 30 days for active disease instead of seven days. And you're decoded only if both of the following criteria are met in the 30 days.
So the first criteria is you determine that the resident had a UTI using evidence-based criteria, such as McGeer, NHSN, or Loeb criteria in the last 30 days. So that's one. And that a physician documented a UTI diagnosis in the last 30 days. Or someone else authorized in your state to do that diagnosis, such as a nurse practitioner a physician assistant.
Then, they go on to add more to the definition. So if the diagnosis of UTI was made prior to the resident's admission, entry, or reentry to the facility, it's not necessary to obtain or evaluate the evidence-based criteria used to make the diagnosis in the prior setting. A documented physician diagnosis of UTI prior to admission is acceptable. And this information may be included on the hospital transfer summary or other paperwork.
It goes on to continue with, when the resident is transferred but not admitted to a hospital-- so for example, an emergency room visit or observation stay-- the facility must use evidence-based criteria to evaluate the resident and determine if the criteria for the UTI are met and verify that there is a physician-documented UTI diagnosis when you are completing MDS item I2300 for UTI. And there's even more information in the RAI Manual on pages I13 through 14 to encourage you to look at the facilities Infection Prevention and Control Program and resources for evidence-based UTI criteria.
So once you've done all of that, now you've got to search for the root cause, which is the fundamental reason why a problem has occurred. So why did our resident get a UTI? Because that would not be performance meeting expectations, that if the resident got a UTI in our facility. So we do the root cause analysis. We may find a variety of potential causes, beginning with errors on the MDS.
So as I said before, was it just a point and click error? Was there coding issues? Were all components of the UTI definition present at the right time in that 30 days? The ARD. Is everyone coding to the one ARD? If we identify that the errors on the MDS aren't a problem, then what is the UTI problem? That will be something that you all in your facility can determine through your root cause analysis.
And what is the difference for you between the prevention strategy versus the intervention strategy? And are there correlations to other quality measures? Are you seeing falls go up when someone has a UTI?
Then, once you've done your root cause analysis, you'll come to the model for improvement. So we always start off with the first three questions. What are we trying to accomplish? The increased facility acquired UTIs. How will we know that a change is an improvement? We're going to track our data. And then, what change can we make that will result in improvement? That's what you're going to find from your root cause analysis.
Then, you'll run a series of plan, do, study, act cycles of quality improvement so you can get to that high level of sustainability. We encourage you to document your quality improvement efforts, and we have a worksheet for testing change for you that sort of lays out that model for improvement on a piece of paper. You can access that in the QAPI resources on our website.
So here's your next steps. Review the coding for the MDS item for this quality measure. Make sure you're reviewing the quality measure specification, as well. And then, complete your root cause analysis and begin your quality improvement project. And be sure to check out the website for more tools and resources. Our website address is tmfnetworks.org. And then, you can hover over the word networks and get the drop down menu for nursing homes, skilled nursing facilities. Or you can email us if you have any questions at NHnetwork@tmf.org. Thank you.