Mastering the QI/QM Report

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re you new to the Minimum Data Set (MDS) Quality Indicators/Quality Measures (QI/QM) report? If so, you probably have some questions. What do all these numbers mean? How do I read this report? How can I teach others how to read this report? This article will be a primer to reading the report and interpreting the data.
       The primary use of the QI/QM report is to identify potential areas of concern for quality assurance (QA) activities. Information reported by the Center for Health Systems Research & Analysis (CHSRA) is the basis for QI, and publicly reported information is the basis for QM; they are now combined. This information comes from the Revised Facility Guide for the Minimum Data Set (MDS) QI/QM Reports from the Centers for Medicare & Medicaid Services (CMS). (To see the guide, visit www.qtso.com/mdsdownload.html and scroll to the bottom).
       The goal is to highlight potential quality of care problems for the facility, so it includes only residents whose most recent MDS assessments and prior assessments are compared to reflect care in the facility. For the numerator, that means that it includes those who have had a complete assessment and a quarterly assessment. The report provides a description of which new conditions have developed over the course of the last 2 assessments. Only those residents with 2 assessments are included. The MDS coordinator typically provides the reports from the state to the interdisciplinary team.
       CMS recommends looking at QI/QM ranks and percentages, clinically linked QI, and previous regulatory survey results (ie, deficiencies). Look for related topics, and make conclusions about the quality of care. If it is a facility-wide problem, devise an improvement initiative. Lastly, evaluate the effectiveness of the improvement plan, based on subsequent QI/QM reports.
       Of particular importance are the starred items. These are focus items that the facility must identity as care concerns. The exact threshold for a starred item is 90%. The higher the percentile, the more potential for a care concern in the facility. Many facilities also look at items that rank at 75% or above.
       For a low-risk group, one would look at how a facility intervenes with residents who are and are not vulnerable to certain conditions. For example, someone who is ambulatory with a developing pressure sore would be classified in a low-risk group. We also know that some ambulatory residents get pressure sores from shoes and that the facility must provide treatment and the means for prevention.
       Now, let us look at CHSRA’s Sentinel Health Event Quality Indicators (ie, Prevalence of Dehydration, Fecal Impaction, and Low-Risk Pressure Ulcer Residents). If any of these indications occur, make sure you have orders addressing the problem, documentation, and a care plan in place. Then look at actual percentages compared to the rate of state and national averages. Your facility may have more of a rehabilitation focus or a more acutely ill population. Take all of that into consideration when looking at these numbers. Look at each item. Look at the actual number of residents in the first column. The names are listed in the Chronic Care Level Report for those being counted.
       One of the most useful MDS reports is the Resident Level Quality Measure/ Indicator Report: Chronic Care Sample. It examines concerns (eg, urinary incontinence or a resident taking 9 or more medications) for the facility. Since pain control is a national concern, the pain domain, with moderate or severe pain, is displayed. A pain control program, with which a pharmacist can be helpful, should be in place.
       The Resident Level Quality Measure/ Indicator Report, Post-Acute Care Sample has columns for delirium, moderate to severe pain, and pressure ulcers. If these columns are marked, the facility should make sure that a good program is in place to address these issues.
       There are 4 conclusions to be drawn from an assessment, based on the following questions from CMS:
1. Was the resident’s condition (related to QI/QM) correctly assessed, reasonable interventions planned, the plan implemented, and the effectiveness evaluated?
2. As a result of your investigation of the QI/QM and these sampled residents, were problems of care identified?
3. Was the quality problem described for this sampled resident and related to this QI/QM of significant magnitude to conclude that there was a quality of care problem for the facility?
4. As a result of the investigation of this QI/QM and this resident, did you identify any other quality problems for [this resident] or other residents/Were there problems related to other QIs/QMs that were potentially problematic?
       Improvement may focus on changes in policy and procedures, training and retraining staff, and supervision. Often, items need to be referred to the pharmacist, medical director, or dietitian. Everyone on the interdisciplinary team will be involved; the best facilities are those that work together to identify, evaluate, and solve problems.
       So, let us look at the first item on the Facility Quality Measure/Indicator Report, “Accidents.” It is divided between incidence of new fractures and prevalence of falls. These items only look at residents who have had 2 assessments and a newly coded fracture.
       Falls are always a concern in nursing homes. The number of residents with falls in the past 30 days is recorded. Is the number high? Is there something the facility could be doing to reduce that number?
       The next one is “Behavior/Emotional Pattern,” an important aspect on how a resident copes with being in a facility and his or her behavior. How is the facility addressing the behaviors? Could the staff look at different interventions?
       Under “Clinical Management,” a resident’s use of 9 or more different medication requires the physician, nurse practitioner, physician’s assistant, and/or pharmacist to make recommendations. Today, many residents take 9 or more medications; more pharmacological interventions are used, and it is difficult to reduce medications.
       “Cognitive Patterns” looks at changes in cognition. After it is acknowledged, could reorientation and activities be increased to maintain previous cognitive skills? Document your plan.
       The next item is “Elimination/ Incontinence.” This is one of the major reasons individuals are institutionalized. A facility must have a plan in place for residents who are incontinent of bowel and bladder, whether it is monitoring and changing briefs or regular toileting. Identify whether someone has a toileting plan. This might make a big difference to an individual’s quality of life and dignity.
       The next item, “Infection Control,” should be a top priority when it comes to urinary tract infections (UTIs). It has been well documented that UTIs should only be marked on the MDS with a lab result of a pathogen in the chart. Nursing home residents frequently have colonized UTIs, which are not considered UTIs for MDS purposes.
       “Nutrition and Eating” is the next concern for the facility. How are the residents eating? Look at weight loss. Make sure physician orders are in place for feeding tubes as well as tube flushes for the prevention of hydration and that they are monitored to prevent problems.
       “Pain Management” is next, followed by “Physical Functioning” and an increased activities of daily living (ADL) assessment. Residents fluctuate, but if there is something a rehabilitation team can do, it should be considered.
       Next is “Psychotropic Drug Use.” Are the diagnoses that are used acceptable? Prevalence of anxiety/hypnotic use should be monitored appropriately.
       The next item, “Quality of Life,” includes such issues as use of restraints and little or no activity. Is yours a restraint-free facility? If there are times when restraints are used, make sure the residents who have restraints have orders, regular assessments, and a team that meets to discuss a program to reduce restraints.
       For “Skin Care,” look at the prevalence rate. This area reflects the care of the resident. See if there is a prevention plan in place as well as treatments for all residents who have pressure ulcers.
       The monthly trend report shows scores on any single item for a given period of time and compares them to state and national averages. The data are displayed in tabular and graphic form. One can see if scores are increasing or decreasing over time. Remember, the QI/QM is a tool for surveyors and the facility to use. It is not to be used exclusively for QA activities.
       Using a process commonly taught in nursing school—assessment, (care) planning, intervention (or implementation), and evaluation–one can see whether a plan of care promotes the best outcomes for the resident based on an accurate and current assessment.
       By having a team approach, one can make sure the MDS is accurate and that chart notes can verify the resident’s condition. If there is an error, it can be corrected. Decide whether the care plan decisions are sound and if care needs to be revised. This tool is invaluable to allow the facility to focus on target areas, but it is not the only tool. Best of luck with all of your team-building and improvement endeavors!

       Editor’s note: For examples of QI/QM reports, visit www.qtso.com/download/mds/qiqm_rpt/Appendix_B_QI_QM_Report_Examples.pdf