Objectives - Great Plains...

4/28/2015

1

What’s Your Number? Understanding the Quality Measure Composite Score

Krystal Hays, RN, MSN, RAC-CT

Jane Stotts, RN, BSN

Quality Improvement Advisors

Great Plains Quality Innovation Network

Objectives

• Identify the significance of the Nursing Home Quality Composite Score

• Calculate your nursing home’s Quality Composite Score

• Develop a plan to decrease and maintain a Nursing Home Quality Composite Score of 6.00 or less

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Polling Question

Are you familiar with the Nursing Home Quality Composite Score?

a. Yes

b. No

3

What is the Nursing Home Quality Composite Measure?

4

• Tool used to help monitor quality from a systems perspective

• Derived from MDS 3.0 data translated into long-stay quality measures on CASPER report

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What the Nursing Home Quality Composite Measure is Not!

5

• It does not replace or supersede the 5-Star Quality Rating System or other local or federal initiatives

Why a Score of 6.00 or Less?

6

• CMS identified 10 high-performing nursing homes

• Average Composite Score of 6.00

• Nationwide, only 10 percent of nursing homes had a Composite Score of 6.00 or less

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7

Isn’t the 5-Star Rating Enough?

8

• 5-Star Quality Measure Ratings are updated quarterly (mid-month January, April, July and October)

• Composite Score can be measured monthly

• Calculated and updated more frequently than 5-Star Quality Rating System

• Nursing homes can calculate their own Composite Score

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Changes to Nursing Home Compare 5-Star Rating System

9

• Effective February 20, 2015

• Addition of two Quality Measures • Antipsychotic medication use in short-stay residents • Antipsychotic medication use in long-stay residents

• Raised the standard to achieve high ratings in Quality

Measures Category

• Adjusted staffing algorithms

Changes to Nursing Home Compare 5-Star Ratings in Nebraska

10

February 13, 2015 February 20, 2015 1 Stars – 14 +17 1 Stars – 31

2 Stars – 39 - 2 2 Stars – 37 3 Stars – 41 - 6 3 Stars – 35 4 Stars – 49 + 1 4 Stars – 50 5 Stars – 72 - 11 5 Stars – 61

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11

What is CASPER?

12

Certification and Survey Provider Enhance Reporting system

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Available CASPER QM Reports

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Polling Question

14

How often does your organization review your CASPER report?

a. Every month b. Every 2 – 4 months c. Every 5 – 7 months d. Never

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CASPER QM Report Page

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Select the QM Reports, Facility ID and Date Range – Submit

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6 month timeframe

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Reports go to Folders

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Facility Quality Measure Report

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Measure Description

CMS

ID

Data

Num

Denom

Facility

Observed

Percent

Facility

Adjusted

Percent

Comparison

Group

State

Average

Comparison

Group

National

Average

Comparison

Group

National

Percentile

SR Mod/Severe Pain (S) N001.01 5 15 33.3%% 33.3% 20.3% 19.3% 86*

SR Mod/Severe Pain (L) N014.01 6 40 15.0% 11.0% 10.0% 8.9% 69

Hi-risk Pres Ulcer (L) N015.01 2 30 6.7% 6.7% 4.9% 7.1% 54

New/worse Pres Ulcer (S) N002.01 1 21 4.8% 4.0% 1.7% 1.4% 91*

Phys restraints (L) N027.01 0 50 0.0% 0.0% 0.7% 1.5% 0

Falls (L) N032.01 31 50 62.0% 62.0% 58.3% 44.5% 90*

Falls w/ Maj Injury (L) N013.01 4 50 8.0% 8.0% 4.8% 3.3% 94*

Antipsych Med (S) N011.01 0 15 0.0% 0.0% 1.9% 2.9% 0

Antipsych Med (L) N031.02 15 48 31.3% 31.3% 21.6% 19.2% 94*

Antianxiety/Hypnotic (L) N033.01 0 26 0.0% 0.0% 7.1% 11.0% 0

Behav Sx affect Others (L) N034.01 1 47 2.1% 2.1% 27.5% 25.0% 3

Depress Sx (L) N030.01 1 48 2.1% 2.1% 7.5% 6.8% 42

UTI (L) N024.01 1 50 2.0% 2.0% 5.3% 6.8% 19

Cath Insert/Left Bladder (L) N026.01 0 48 0.0% 0.0% 3.9% 4.1% 0

Lo-Risk Lose B/B Con (L) N025.01 12 31 38.7% 38.7% 43.4% 43.5% 40

Data provided is fictional

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Measure Description

CMS

ID

Data

Num

Denom

Facility

Observed

Percent

Facility

Adjusted

Percent

Comparison

Group

State

Average

Comparison

Group

National

Average

Comparison

Group

National

Percentile






Falls (L) N032.01 31 50 62.0% 62.0% 58.3% 44.5% 90*


Antipsych Med (S) N011.01 0 15 0.0% 0.0% 1.9% 2.9% 0

Antipsych Med (L) N031.02 15 48 31.3% 31.3% 21.6% 19.2% 94*



Depress Sx (L) N030.01 1 48 2.1% 2.1% 7.5% 6.8% 42

UTI (L) N024.01 1 50 2.0% 2.0% 5.3% 6.8% 19




Short Stay vs. Long Stay

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• Total Cumulative Days spent in facility • Days out of facility not included (hospital, home)

• Resident is classified as Short- or Long-Stay

• Short Stay = Total cumulative days ≤ 100

• Long Stay = Total cumulative days ≥ 101

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21

Measure Description

CMS

ID

Data

Num

Denom

Facility

Observed

Percent

Facility

Adjusted

Percent

Comparison

Group

State

Average

Comparison

Group

National

Average

Comparison

Group

National

Percentile






Falls (L) N032.01 31 50 62.0% 62.0% 58.3% 44.5% 90*


Antipsych Med (S) N011.01 0 15 0.0% 0.0% 1.9% 2.9% 0

Antipsych Med (L) N031.02 15 48 31.3% 31.3% 21.6% 19.2% 94*



Depress Sx (L) N030.01 1 48 2.1% 2.1% 7.5% 6.8% 42

UTI (L) N024.01 1 50 2.0% 2.0% 5.3% 6.8% 19




Definitions

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Denominator – number of residents potentially impacted by the QM condition during the report period

Numerator – actual number of residents who were impacted by the QM condition during the report period

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Why is the Denominator Different?

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• Short stay vs. Long stay • Only residents who are not excluded from the Quality

Measure are counted in the denominator • The Antipsychotic Quality Measure excludes

Schizophrenia, Tourette’s Syndrome and Huntington’s Disease

• Some Quality Measures exclude the admission assessment or the 5 Day PPS assessment


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Measure Description

CMS

ID

Data

Num

Denom

Facility

Observed

Percent

Facility

Adjusted

Percent

Comparison

Group

State

Average

Comparison

Group

National

Average

Comparison

Group

National

Percentile






Falls (L) N032.01 31 50 62.0% 62.0% 58.3% 44.5% 90*


Antipsych Med (S) N011.01 0 15 0.0% 0.0% 1.9% 2.9% 0

Antipsych Med (L) N031.02 15 48 31.3% 31.3% 21.6% 19.2% 94*



Depress Sx (L) N030.01 1 48 2.1% 2.1% 7.5% 6.8% 42

UTI (L) N024.01 1 50 2.0% 2.0% 5.3% 6.8% 19




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Calculating the QM Percentage

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Numerator divided by the denominator multiplied by 100 Example: Antipsychotic Med (Long Stay) QM __15___ / __48__ x 100 = __31.3%___

Measure Description

CMS

ID

Data

Num

Denom

Facility

Observed

Percent

Facility

Adjusted

Percent

Comparison

Group

State

Average

Comparison

Group

National

Average

Comparison

Group

National

Percentile

Antipsych Med (L)

N031.02

15

48

31.3%

31.3%

18.9%

21.3%

94*


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Measure Description

CMS

ID

Data

Num

Denom

Facility

Observed

Percent

Facility

Adjusted

Percent

Comparison

Group

State

Average

Comparison

Group

National

Average

Comparison

Group

National

Percentile






Falls (L) N032.01 31 50 62.0% 62.0% 58.3% 44.5% 90*


Antipsych Med (S) N011.01 0 15 0.0% 0.0% 1.9% 2.9% 0

Antipsych Med (L) N031.02 15 48 31.3% 31.3% 21.6% 19.2% 94*



Depress Sx (L) N030.01 1 48 2.1% 2.1% 7.5% 6.8% 42

UTI (L) N024.01 1 50 2.0% 2.0% 5.3% 6.8% 19




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Measure Description

CMS

ID

Data

Num

Denom

Facility

Observed

Percent

Facility

Adjusted

Percent

Comparison

Group

State

Average

Comparison

Group

National

Average

Comparison

Group

National

Percentile






Falls (L) N032.01 31 50 62.0% 62.0% 58.3% 44.5% 90*


Antipsych Med (S) N011.01 0 15 0.0% 0.0% 1.9% 2.9% 0

Antipsych Med (L) N031.02 15 48 31.3% 31.3% 21.6% 19.2% 94*



Depress Sx (L) N030.01 1 48 2.1% 2.1% 7.5% 6.8% 42

UTI (L) N024.01 1 50 2.0% 2.0% 5.3% 6.8% 19




Resident Level Report

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Resident Name Resident ID A0310A/B/F

SR M

od

/Sev

ere

Pai

n (

S)

SR M

od

/Sev

ere

Pai

n (

L)

Hi-

risk

Pre

s U

lcer

(L)

New

/wo

rse

Pre

s U

lcer

(S)

Ph

ys r

estr

ain

ts (

L)

Fall

(L)

Falls

w/

Maj

Inju

ry (L

)

An

tip

sych

Med

s (S

)

An

tip

sych

Med

(L)

An

tian

xiet

y/H

ypn

oti

c (L

)

Beh

av S

x A

ffec

t O

ther

s (L

)

De

pre

ss S

x (L

)

UTI

(L)

Cat

h In

sert

/Lef

t B

lad

der

(L)

Lo-R

isk

Lose

B/B

Co

n (

L)

Exce

ss W

t Lo

ss (

L)

Incr

AD

L H

elp

(L)

Qu

alit

y M

easu

re C

ou

nt

Resident A 10001 04/99/99 X X X X 4

Resident B 10002 99/99/11 X X X X X X X 7

Resident C 10003 02/99/99 1

Resident D 10004 04/99/99 X X X X 4

Resident E 10005 99/99/11 X X X 4

Resident F 10006 02/99/99 X X X 3

Resident G 10007 04/99/99 X X X X X 5

Resident H 10008 99/99/11 X X X 3

Resident I 10009 02/99/99 X X X X X 5


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Resident Level Report

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Resident Name Resident ID A0310A/B/F

SR M

od

/Se

vere

Pai

n (

S)

SR M

od

/Se

vere

Pai

n (

L)

Hi-

risk

Pre

s U

lce

r (L

)

Ne

w/w

ors

e P

res

Ulc

er

(S)

Ph

ys r

est

rain

ts (

L)

Fall

(L)

Falls

w/

Maj

Inju

ry (L

)

An

tip

sych

Me

ds

(S)

An

tip

sych

Me

d (

L)

An

tian

xie

ty/H

ypn

oti

c (L

)

Be

hav

Sx

Aff

ect

Oth

ers

(L)

De

pre

ss S

x (L

)

UTI

(L)

Cat

h In

sert

/Le

ft B

lad

de

r (L

)

Lo-R

isk

Lose

B/B

Co

n (

L)

Exce

ss W

t Lo

ss (

L)

Incr

AD

L H

elp

(L)

Qu

alit

y M

eas

ure

Co

un

t

Resident A 10001 04/99/99 X X X X 4

Resident B 10002 99/99/11 X X X X X X X 7

Resident C 10003 02/99/99 1

Resident D 10004 04/99/99 X X X X 4

Resident E 10005 99/99/11 X X X 4

Resident F 10006 02/99/99 X X X 3

Resident G 10007 04/99/99 X X X X X 5

Resident H 10008 99/99/11 X X X 3

Resident I 10009 02/99/99 X X X X X 5


How do I Calculate my Facility’s Composite Score?

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• CASPER Facility Quality Measure Report

• Influenza and Pneumococcal Vaccine MDS 3.0 Data

• Calculate by hand

• Composite Score Calculator

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What Quality Measures are Included?

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13 NQF-endorsed publically reported, long-stay QMs: • Falls with major injury • Urinary Tract Infections • Self-reported moderate to severe pain • High-risk residents with pressure ulcers • Low-risk residents with loss of bowel or bladder • Residents with catheter inserted or left in bladder • Physically restrained residents • Residents needing increased help with ADLs • Weight loss • Residents with depressive symptoms • Residents receiving antipsychotic medications • Residents given Influenza vaccine** • Residents given Pneumococcal vaccine** **Not found on CASPER report

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Measure Description

CMS

ID

Data

Num

Denom

Facility

Observed

Percent

Facility

Adjusted

Percent

Comparison

Group

State

Average

Comparison

Group

National

Average

Comparison

Group

National

Percentile






Falls (L) N032.01 31 50 62.0% 62.0% 58.3% 44.5% 90*


Antipsych Med (S) N011.01 0 15 0.0% 0.0% 1.9% 2.9% 0

Antipsych Med (L) N031.02 15 48 31.3% 31.3% 21.6% 19.2% 94*



Depress Sx (L) N030.01 1 48 2.1% 2.1% 7.5% 6.8% 42

UTI (L) N024.01 1 50 2.0% 2.0% 5.3% 6.8% 19



Excess Wt Loss (L) N029.01 1 50 2.0% 2.0% 8.5% 8.8% 9

Incr ADL Help (L) N028.01 5 46 10.9% 10.9% 16.3% 16.2% 28


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Influenza & Pneumococcal QM

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• Not a Quality Measure on CASPER report

• Calculated with current facility data

• QIN-QIO can provide current CMS data calculation derived from MDS 3.0 submissions

Influenza Vaccine Numerator

34

Goal: Appropriately vaccinate all residents Resident meets any of the following on MDS 3.0:

• Received influenza vaccine during the current or most recent influenza season, either in the facility (O0250A = 1) or outside the facility (O0250C = 2)

• Offered and declined the influenza vaccine (O0250C = 4)

• Ineligible due to contraindications (O0250C = 3)

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Pneumococcal Vaccine Numerator

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Goal: Know pneumococcal status of all residents Resident meets any of the following on MDS 3.0:

• Up to date Pneumococcal Vaccine status (O0300A = 1) • Offered and declined the Pneumococcal vaccine

(O0300B = 2) • Ineligible due to medical contraindications

(O0300B = 1)

“Reverse” Numerator Calculation for Influenza Vaccine

36

Influenza Vaccine Example • 48 residents have met the requirements to be

counted in the Influenza Quality Measure • 50 residents are currently in the facility

Reverse Numerator: 50 residents possible – 48 actually impacted = 2 When calculating the Composite Score • Numerator = 2 • Denominator = 50

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“Reverse” Numerator Calculation for Pneumococcal Vaccine

37

Pneumococcal Vaccine Example • 50 residents have met the requirements to be

counted in the Pneumococcal Quality Measure • 50 residents are currently in the facility

Reverse Numerator: 50 residents possible – 50 actually impacted = 0 When calculating the Composite Score • Numerator = 0 • Denominator = 50

How does the Seasonal Influenza Vaccine Affect my Score?

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Two periods of fluctuations:

• Time period ends at the beginning or during the flu season, when many residents haven’t been assessed and appropriately given the vaccine

• Definition of “current” flu season varies among healthcare providers and across states

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Measure Description

CMS

ID

Data

Num

Denom

SR Mod/Severe Pain (S) N001.01 5 15

SR Mod/Severe Pain (L) N014.01 6 40

Hi-risk Pres Ulcer (L) N015.01 2 30

New/worse Pres Ulcer (S) N002.01 1 21

Phys restraints (L) N027.01 0 50

Falls (L) N032.01 31 50

Falls w/ Maj Injury (L) N013.01 4 50

Antipsych Med (S) N011.01 0 15

Antipsych Med (L) N031.02 15 48

Antianxiety/Hypnotic (L) N033.01 0 26

Behav Sx affect Others (L) N034.01 1 47

Depress Sx (L) N030.01 1 48

UTI (L) N024.01 1 50

Cath Insert/Left Bladder (L) N026.01 0 48

Lo-Risk Lose B/B Con (L) N025.01 12 31

Excess Wt Loss (L) N029.01 1 50

Incr ADL Help (L) N028.01 5 46

Influenza Vaccine (reverse numerator) 2 50 Pneumococcal Vaccine (reverse numerator) 0 50 -------- -------- 49 591

Total Sum of 13 QM’s Numerator = 49 Denominator = 591 49/591 * 100 = 8.29 Composite Score = 8.29

Manual Composite Score Calculation

Composite Calculator

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Measure Description Current

Numerator Denominator

Facility Composite Percentage

Estimated Numerator

Recalculated Facility Composite Percentage

Percent of Change from Current Numerator to Estimated Numerator

SR Mod/Severe Pain (L) 6 40 15.00% 4 10.00% -33.33%

Hi-risk Pres Ulcer (L) 2 30 6.67% 0 0.00% -100.00%

Phys Restraints (L) 0 50 0.00% 0 0.00% 0.00%

Falls w/Maj Injury (L) 4 50 8.00% 2 4.00% -50.00%

Antipsyc Med (L) 15 48 31.25% 12 25.00% -20.00%

Depress Sx (L) 1 48 2.08% 1 2.08% 0.00%

UTI (L) 1 50 2.00% 0 0.00% -100.00%

Cath Insert/Left Bladder (L) 0 48 0.00% 0 0.00% 0.00%

Lo-Risk Lose B/B Con (L) 12 31 38.71% 12 38.71% 0.00%

Excess Wt Loss (L) 1 50 2.00% 1 2.00% 0.00%

Incr ADL Help (L) 5 46 10.87% 4 8.70% -20.00%

Influenza Vaccine 0 50 0.00% 0 0.00% 0.00%

Pneumococcal Vaccine 0 50 0.00% 0 0.00% 0.00%

Composite 47 591 7.95 36 6.09 -23.40% Updated 02/06/2015 Data provided is fictional

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Putting it all Together: Next Steps

41

• Run monthly CASPER Facility Quality Measure Report and Resident Level Characteristics Report. • Use six-month timeframe

• Any QMs above 75 in the “Comparison Group National Percentile” column? • Any QMs above state and national averages? • Calculate your facility Composite Score and look for areas with high “facility

composite percentages”

• Using the Composite Calculator, reduce QM numerators in areas with high “facility composite percentages” to determine QM goals

When Reviewing QMs, Does a QAPI Opportunity Exist?

42

• Set facility QM goals • Example: Reduce long-stay antipsychotic rates to less than 10% in the

“Facility Observed Rate” on the CASPER QM Facility Report. • Look for trends by using the Resident Level Characteristics report

• Ask yourself, why are they triggering? • Could there be a coding error? • Example: Are the majority of residents with falls with injury also on

an antipsychotic? • Further analyze the QM numbers and review:

• Quality Measures User’s Manual and Measure Specifications • RAI MDS 3.0 Manual • Verify that coding is accurate for MDS items and Assessment

Reference Dates (ARD)

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Once a Quality Measure is Selected…

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• Establish baseline (starting point) • Set benchmark (what do you want it to be?) • Root Cause Analysis (why is this QM high?) • Form a Performance Improvement Team • Implement the Plan-Do-Study-Act (PDSA) cycle • Keep the goal and progress in the forefront – track

the data • Communicate status /celebrate successes

Resources

44

MDS 3.0 RAI Manual: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

MDS 3.0 Quality Measures User Manual: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html

Nursing Home Compare Five-Star Rating System: http://www.cms.gov/Medicare/Provider-Enrollment-and-certification/CertificationandComplianc/FSQRS.html

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html











http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html













http://www.cms.gov/Medicare/Provider-Enrollment-and-certification/CertificationandComplianc/FSQRS.html








4/28/2015

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Open Office Hours

Topic: National Nursing Home

Quality Composite Score

Thursday, May 7, 2015

2:00 – 3:00 p.m. CST

Call: 1-800-689-9374

Passcode: 560493

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Technical Assistance

Contact Krystal Hays to set an appointment

for an individualized teleconference for

Quality Composite Score technical assistance

[email protected]

402.476.1399 ext. 522

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mailto:[email protected]



4/28/2015

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Upcoming Collaborative Event

GPQCC Learning Session 1

The Importance of Quality: Because the Rest of

Someone’s Life is Counting on It

Tuesday, June 2 - Holiday Inn, Kearney

Wednesday, June 3 - Cornhusker Hotel, Lincoln

9:00 a.m. to 4:00 p.m.

Presenter: Marguerite McLaughlin

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Upcoming CIMRO of Nebraska Event

2015 Nebraska Healthcare Quality Forum

Thursday, May 14, 2015

7:30 a.m. to 4:00 p.m.

Embassy Suites Hotel & Conference Center

La Vista, Nebraska

www.greatplainsqin.org/qualityforum

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http://www.greatplainsqin.org/qualityforum

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Contact Information

Krystal Hays, RN, MSN, RAC-CT [email protected]

Jane Stotts, RN, BSN

[email protected]

1200 Libra Drive, Suite 102 Lincoln, Nebraska 68512

P: 402.476.1399 | F: 402.476.1335

This material was prepared the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11S0W-GPQIN-NE-C2-27/0415







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