AGING AND DISABILITY SERVICES ADMINISTRATION

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Quality Measure/Quality Indicator (QM/QI) Reports

Quality Indicator and Quality Measure Reports present data on 30 quality measures/indicators (34 with subcategories) during a quarter. The data is presented at the patient, facility, state, and national levels.

Manual for Nursing Homes

There is a 64-page manual that all facilities should have in order to understand quality indicators. It was originally distributed in 1999 during provider training and has been listed as a resource in every RAI training session provided by Department of Social and Health Services in Washington State since 2001. See it online at www.qtso.com . Once at the website, select ‘MDS’ from the menu at the side of the screen and arrow down to facility guide for nursing home quality indicators.

Question:
The numbers on the Facility Quality Indicator Profile do not match what is on the Resident Level Quality Indicator Summary. Isn’t the facility report supposed to be a roll-up of the resident report?
Answer:
Actually, no. The Facility Quality Indicator Profile does not include information for residents who are new admissions, since the MDS information for them is likely to reflect care they received while outside of the facility. However, the Resident Level Quality Indicator Summary includes information for all resident assessments. Therefore, the numbers can be different: the numbers listed in the facility report may be lower than the numbers you add up in the resident report.

 Reports for the Public

1. The MDS Quality Measure/Indicator (QM/QI) Report summarizes, by state, the average percentage of nursing home residents who activate (trigger) one of 30 quality measures/indicators (34 with subcategories) during a quarter. This public information is available at:  http://www.cms.hhs.gov/MDSPubQIandResRep/02_qmreport.asp#TopOfPage

2. The public can receive copies of facility specific QI information directly from a facility in the community (see item 2 below).
3. Nursing Home Compare is an online web site that provides information about performance for nursing homes that are Medicare or Medicaid certified in all fifty U.S. states and territories.  You can get data to help you evaluate a nursing home, including nursing home characteristics (such as number of beds and type of ownership), quality measures (such as the percent of residents who have bed sores, infections or pain), state inspection results, and the average number of hours worked by nursing home staff per resident per day.
   Go to www.medicare.gov/NHCompare and select nursing homes by geographic area or name.   

 Reports for Nursing Homes

1. “Facility QI Profile” and “Resident QI Summary” - Nursing homes can obtain detailed QI reports for use as a tool in each nursing facility's own quality assurance work.  The reports are located in the CMS MDS system under “Analytic Reports” on the MDS Welcome Page and are entitled:  “Facility QI Profile” and “Resident QI Summary.” This report is generated as a result of MDS input and nursing homes enter the desired query parameters to generate their reports.
2. On the “QIES to Success” website ‘MDS Express Reports’ are available and include national QI reports.  This is Oracle Express, an ad hoc generator of data views.  Online training is provided by QTSO.