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Quality Indicator Report: Chronic Quality Measures
Susan duLaney RN CWCN
Tara-Lynne Bixenman RN BSN
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Facility Quality Measure/Indicator Report
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Example of what the report looks like:
Two Major Steps in Calculation
• The measures contained on the Quality Measure/Quality Indicator (QM/QI) Report are calculated in two major steps:― Chronic care sample― Post acute care sample
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Report Contents and Indications
• This report shows each of the QM/QI, the facility percentage, and how the facility compares with other facilities in the State and the nation
• The QM/QI reports are not definite measures of quality of care but are “pointers” that indicate potential problem areas that need further review and investigation
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Three Sections of the Report
• The report is divided into three distinct sections:– Domain/Measure Description– Facility Statistics– Comparison Group
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Chronic Care Quality Measures
Purposes of the Measures
• Nursing home quality measures have four intended purposes:– To give information about the care at nursing homes
to help the consumer choose a nursing home for himself or others;
– To give information to the consumer or family members about the care at nursing homes where the resident lives;
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Purpose of the Measures (cont.)
– To get the consumer to talk to nursing home staff about the quality of care; and
– To provide data to the nursing home to help them with their quality improvement efforts
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Types of Chronic Care Residents
• Chronic care refers to the types of residents who enter a nursing facility typically because they no longer are able to care for themselves at home
• These residents tend to remain in the nursing
facility anywhere from several months to several years
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Function of the Chronic Care Quality Measures • Chronic Care Quality Measures (QM/QI) are
calculated based upon data from any residents with a full or quarterly Minimum Data Set (MDS) in the target assessment period; this allows for comparison over two quarters
• These measures offer a snapshot of the facility at a point in time and allow for comparison to other facilities
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Incidence Measures
• Incidence Measures are conditions that have developed over the course of two assessments (a comparison of two assessments) – The data is collected from the most recent MDS and
the MDS completed immediately prior to the most recent assessment
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Prevalence Measures
• Prevalence Measures are based upon a single assessment. This type of measure provides information about a specific point in time.
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QM/QI Report: Definitions
Numerator
• Numerator: The number of facility residents who actually triggered for a Quality Measure/Quality Indicator (QM/QI)– These are residents who are included in the QM/QI
calculation after the exclusions are applied
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Denominator
• Denominator: This entry defines whether a resident has the necessary records available to be a candidate for the QM– The resident will be included in the denominator for
the QM rate in the facility
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Exclusions
• Exclusions: This entry provides clinical conditions and missing data conditions that would preclude a resident from consideration for the QM.– An excluded resident is excluded from both the
numerator and denominator of the QM rate for the facility
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Exclusions (cont.)
– All Chronic Care QMs have specific exclusions unique to that measure.
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Facility Observed Percent
• Facility Observed Percent:– The percentage is determined by calculating the
number of residents that have each characteristic with the total number of residents
• This is calculated by dividing the numerator by the denominator (example: 3/86 = 0.0348 x 100 = 03.4%)
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Covariates/Risk Adjustment
• Covariates/Risk Adjustment: This entry defines the calculation logic for covariates – Covariates always have a prevalence value of 1 if the
condition is present and a value of 0 if the condition is not present
• Only three Chronic Care QM/QI have covariates– 5.2 Residents who have/had a catheter inserted and left in
the bladder– 8.1 Residents who have moderate to severe pain– 9.3 Residents whose ability to move in and around their
room decreased
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State/National Averages
• State/National Averages: A facility with a high percentile ranking means that the nursing facility has a higher percentage of residents with the presence of the QI than the comparison group
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State Percentile
• State percentile: A facility’s ranking among other facilities in the State, expressed as a percentage– i.e., If a facility is 85%, it means that 85% of the
facilities in the State had a QM/QI less than or equal to the facility’s score.
• Review any QM where the State Percentile is ranked at 75% or higher
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Thresholds
• Thresholds: Set points for QM/QI at which the likelihood of a problem is sufficient to warrant emphasis or at least an investigation by the facility or the survey team
• Measures that exceed these threshold are “flagged” with an asterisk on the report
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Sentinel Events
• Sentinel Events: – There are three QMs that qualify
• 5.4 Prevalence of fecal impaction• 7.3 Prevalence of dehydration• 12.2 Low-risk residents with pressures
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Fourteen Chronic Care QMs:Time Frames
Time Frames
Time frame for each of the 13 Chronic Care QMs:1. Percent of long-stay residents given the influenza
vaccine (between October 1 and March 31)
2. Percent of long-stay residents given the pneumococcal vaccine (looks back 5 years)
3. Percent of residents whose need for help with activities of daily living (ADLs) has increased (looks back 7 days)
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Time Frames (cont.)
4. Percent of residents who have moderate to severe
pain (looks back 7 days)
5. Percent of high-risk residents who have pressure
ulcers (looks back 7 days)
6. Percent of low-risk residents who have pressure
ulcers (looks back 7 days)
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Time Frames (cont.)
7. Percent of residents who spend most of their time in
bed or in a chair (looks back 7 days)
8.Percent of residents whose ability to move about in
and around in their room got worse (looks back 7 days)
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Time Frames (cont.)
9. Percent of residents who were physically restrained
(looks back 7 days)
10. Percent of residents who are more depressed or
anxious (looks back 30 days)
11.Percent of low-risk residents who lose control of
the bowels or bladder (looks back 14 days)
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Time Frames (cont.)
12. Percent of residents with a urinary tract infection
(looks back 30 days)
13. Percent of residents who lose too much weight
(looks back 7 days)
14. Percentage of residents who have had a catheter inserted and left in their bladder (looks back 14 days)
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The Correlation of the MDS and the QM/QI Report
MDS Data Generate the Reports
• After the facility completes and transmits the MDS to the appropriate regulatory agency, the data is used to generate quality indicator reports
• It is essential that the MDS be coded accurately to reflect the nursing facility’s residents and the care provided to them
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Handouts
Refer to the handout package
Appendix A Technical Specifications
Using The Reports
Report Specifics
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Accidents
The MDS items relating to fractures are:• Hip fracture in the in the last 180 days [J4C]• Other fractures in last 180 days [J4d].
– Only one of the above needs to be coded on the MDS to trigger the QM
– It will be necessary to obtain adequate medical records from previous health care facilities
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Accidents (cont.)
• Numerator: Residents with new fractures who have J4c orJ4d [t-1] checked on a target assessment and not checked on a prior assessment
• Denominator: All residents with a valid target assessment and a valid prior assessment who did not have fractures (J4c[t-1] or J4d[t-1]) is not checked
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Accidents (cont.)
• The related MDS specifically relates to falls in the last 30 days [J4a] (refer to MDS handout page 2)
The indicator considers the data from the current MDS assessment
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Accidents (cont.)
• MDS item J4a is an exception to the 7-day assessment rule. It is important to count the actual days rather than considering just one month before the assessment reference date .
• If J4b (fell in 31-180 days) is checked, it will not influence this quality indicator
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Physical Restraint Domain
• Refer to handout for Physical Restraints
• Reflects the percent of residents that were physically restrained during the 7 day assessment period
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Avoiding Assessment Errors
• It is imperative that the MDS accurately reflect the resident and the care provided
• Using proper assessment techniques helps to minimize errors
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Avoiding Assessment Errors (cont.)
• Understand exactly what the question is asking– Refer to the Resident Assessment Instrument (RAI)
manual to determine how to code a correct response
• One incorrect code can affect the quality indicator and may indicate to regulatory surveyors the presence of a care problem that does not exist
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Avoiding Assessment Errors (cont.)
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Incorrect quality indicator scores may suggest to surveyors the presence of a care problem that does not exist and could penalize the facility in the following ways:– Result in Civil Money Penalties (CMP)– Loss of Medicare/Medicaid Funding
• Losing the Provider Number
– Facility closure• Resident Eviction• Staff Unemployment
For assistance contactPatient Safety NH Team:
Beth Hercher
QI Specialist
Direct: 901.273.2640
Fax: 901.761.3786
Tiresa Parker, R.N., C
QI/Compliance Specialist
Tara-Lynne Bixenman RN
QI Specialist
Direct: 615.574.7210
Fax: 615.259.1291
Laurie Gyscek, BSN
Nursing Home Manager
Direct: 615.574.7201
Fax: 615.259.1291
Susan duLaney, RN, CWCN
Wound Care Quality Specialist
Direct: 615.574.7203
Fax: 615.259.1291
• xThis presentation and related materials were developed by QSource, the Medicare Quality Improvement Organization for Tennessee, under contract with the Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health and Human Services. Contents to not necessarily reflect CMS policy. QSource-TN-PS-2009-34
