Characteristics
Quality Indicator/Quality Measure Profile
Quality Indicator/Quality Measure History
Resident Quality Indicator/Quality Measure Summary
Individual Quality Indicator/Quality Measure Series
Resident Listing
Assessment Summary
Data Submission Summary
Quality Indicator/Quality Measure Graphs

(Click to view a sample set of reports)

The Characteristics report can be run based on three different population bases:

• Facility Characteristics - Chronic Care
• Facility Characteristics - Post Acute Care
• Sub-unit Characteristics - Chronic Care

This report contains demographic information by percentages both for the facility and for the comparison group. Remember that while facility percentages can be very informative, the best information is often gained by viewing differences between your facility's results and the results of the comparison group.

How to Use the Characteristics Report
This report can be used to help identify possible areas for further emphasis or review as part of a survey or a facility's quality assurance/improvement process. Any of the following results may indicate a need to concentrate a review on certain resident groups:

• A very old population or an unusually high number of male residents.
• A higher than average percentage of Medicare as a payment source, which may indicate an emphasis on rehabilitation or a more acutely ill population.
• A higher than average percentage of psychiatric and mentally retarded residents or those receiving hospice care.
• Higher than average percentages of admission assessments or significant change assessments.

The Quality Indicator/Quality Measure Profile report can be run based on three different population bases:

• Facility Quality Indicator/Quality Measure Profile - Chronic Care
• Facility Quality Indicator/Quality Measure Profile - Post Acute Care
• Sub-unit Quality Indicator/Quality Measure Profile - Chronic Care

This report shows each QI/QM separated by domain, the facility percentage and how the facility compares with other facilities in the comparison group. The comparisons group's results are shown using both percentages and a ranking system. This report helps you to identify possible areas for further emphasis in facility quality improvement activities or investigation during the survey process. Because the goal is to highlight potential quality of care problems for the facility, this report includes only residents for whom the most recent assessment is likely to reflect care in the facility. It does not include information for residents who are new admissions, since the MDS information for them is likely to reflect the care they received while outside of the facility.

The information on the Quality Indicator/Quality Measure Profile report is presented in several columns:

The first column is "Number in the Numerator." This is the actual number of residents who flagged on the QI/QM. These are the people who "have" the QI/QM. For the purposes of calculating the percentage(s), it is the numerator.

The second column is "Number in the Denominator." This is the number of people in the facility who "could have" the QI/QM. For the purposes of calculating percentage(s), it is the denominator. So, out of the number of people who "could have" or could flag on the QI/QM, the first column is the number who actually did. Most of the time, the number of residents who could have the QI/QM will be the total population, excluding those whose most recent assessment is for an admission; but there are some QI/QMs that use a specific sub-group as those who "could have" the QI/QM. A good example of this sub-group is the QI/QM 10.1 "Antipsychotic Use in the Absence of Psychotic and Related Conditions". The only residents who "could have" this QI/QM are those without a psychotic disorder or other related conditions. In the case of incidence QI/QMs, the group of residents who could have the QI/QM includes only people who did not have the QI/QM condition in the previous period. This is because incidence QI/QMs measure the development of the QI/QM where it did not exist previously. An example of an incidence QI/QM with a specific sub-group is QI/QM 4.1 "Incidence of Cognitive Impairment". The denominator ("could have it") for this QI/QM is only those residents who, on their previous assessment, were not cognitively impaired and on their current assessment are cognitively impaired.

The third column is the "Facility Percentage." This column tells you what percentage of residents who could have the QI/QM actually did have it. If 60 people could flag on a QI/QM (denominator, column 2) and 30 people actually did have it (numerator, column 1), the facility proportion (percentage, ratio) would be 50%. The numbers in parentheses ( ) are adjusted using the new CMS risk adjustment process.

The fourth column is the "Comparison Group Percentage." This column tells you what the comparison group percentage is for the QI/QM so that you may make comparisons with the facility. This column can be very helpful in pointing toward those facilities that may be way above or below the comparison group percentage or proportion. These facilities are called "outliers," meaning their percentages are out of line with respect to the rest of the comparison group. The numbers in parentheses ( ) are adjusted using the new CMS risk adjustment process.

The fifth column is the "Percentile Rank." This column ranks facilities relative to other facilities in the comparison group on each QI/QM. The higher the ranking, the more likely the QI/QM needs to be reviewed as part of the facility quality improvement process or emphasized on the survey. The numbers in parentheses ( ) are adjusted using the new CMS risk adjustment process.

The sixth column identifies those QI/QMs that have crossed an investigative threshold. This column identifies those QI/QMs where the facility ranking is high enough that it should be investigated or emphasized on the survey or in any internal quality improvement initiative. It means that this facility's performance on this particular QI/QM is higher than some critical value, and there is a possible concern for the quality of care. It is an area to highlight for investigation or emphasis during off-site survey preparation or to choose for review in the facility QA/QI process. QI/QMs in this column at or above the 90th percentile will be designated with a flag. All Sentinel Health Event Quality Indicators (i.e., Prevalence of Dehydration, Prevalence of Fecal Impaction, and Low-Risk Residents with Pressure Ulcers) with one or more occurrences will also be designated with a flag.

Remember that just because a QI/QM has flagged (exceeded a threshold) does not mean that there is an automatic assumption of a problem. It means that the information suggests that there is a concern that should be reviewed to see whether a problem exists and how it is being addressed. Remember also that just because a facility does not flag does not mean that there is no problem with the quality of care in that area. You need to consider all of the information provided, and use your best clinical judgment. The QI/QM information is only a tool for surveyors and facility staff to use. It is not to be used exclusively for quality assurance/improvement activities or to make assumptions about care.

How to Use the Quality Indicator/Quality Measure Profile Report
This report is used by the facility to identify areas of potential concern for the QA/QI review using the following steps:

• Step 1 - Choose all QI/QMs for which the facility is ranked on or above the 90th percentile, or any percentile level the facility may wish to choose, as concerns for the review. Determine whether any of the QI/QMs above the selected percentile threshold are clinically linked to each other. It may be reasonable to review these QI/QMs as a group (see TABLE 1, Clinically Linked QI/QMs, below).
• Step 2 - Choose all Sentinel Health Event Quality Indicators (i.e., Prevalence of Dehydration, Prevalence of Fecal Impaction or Low-Risk Residents with Pressure Ulcers) where even one occurrence is sufficient to warrant review.
• Step 3 - Look at the actual percentages of the facility compared to the peer group. Are there any ratios that are of particular concern even though the facility does not rank very high? For example, 50% of the residents are involved in little or no activities.
• Step 4 - Identify the actual number of residents that flag (have the condition represented by the QI/QM). This will help in determining the prevalence of the condition in the facility and may also help approximate the number of residents with the QI/QM that should be considered for inclusion in a review sample.

TABLE 1
Clinical Links Among Domains and Chronic QI/QMs

The Quality Indicator/Quality Measure History report can be run based on three different population bases:

• Facility Quality Indicator/Quality Measure History - Chronic Care
• Facility Quality Indicator/Quality Measure History - Post Acute Care
• Sub-unit Quality Indicator/Quality Measure History - Chronic Care

This report is a list of your facility's QI/QM percentage for the current quarter and your facility's QI/QM percentages for the previous four quarters.

How to Use the Quality Indicator/Quality Measure History Report
This report can be used to view your populations QI/QM percentages over time and to see trends or changes and compare these results to the comparison group percentages.

The Resident Quality Indicator/Quality Measure Summary report can be run based on three different population bases:

• Resident Quality Indicator/Quality Measure Summary - Chronic Care
• Resident Quality Indicator/Quality Measure Summary - Post Acute Care
• Resident Quality Indicator/Quality Measure Summary - Chronic Care (for Sub-unit)

This report lists each resident from left to right, by name, assessment date and reason for assessment. Assessment reasons reflect what was coded and transmitted in the AA8a and AA8b MDS fields. These codes range from 0 through 10 and include:

Following the resident name and assessment information are separate columns for each QI/QM, including high and low risk. A dot appears in the QI/QM column when the resident "flags" on that QI/QM. At the far right end of the Resident Level Summary is a count of the total number of QI/QMs that flagged for the resident. Current residents appear first in the report, followed by residents that were discharged after the assessment date used for the QI/QM report and before the end date for the report period.

Example-- John Doe has a dot in the QI/QM columns for Prevalence of Falls, Use of 9+ Medications, Prevalence of Fecal Impaction, and Prevalence of Little or No Activity. This means that John Doe had these conditions or situations occur during the assessment period identified on the report and he "flagged" on a total of 4 QI/QMs. The report may also be read vertically to quickly identify all residents with a specific QI/QM.

How to Use the Resident Quality Indicator/Quality Measure Summary Report
This report can assist in choosing concerns for facility review, but to a lesser degree than the Quality Indicator/Quality Measure Profile Report. The Resident Quality Indicator/Quality Measure Summary Report can establish patterns between QI/QMs. Consideration should be given to choosing QI/QMs as concerns for facility review that show strong patterns and to selecting residents who have similar patterns.

The Individual Quality Indicator/Quality Measure Series report can be run based on three different population bases:

• Individual Quality Indicator/Quality Measure Series - Chronic Care
• Individual Quality Indicator/Quality Measure Series - Post Acute Care
• Individual Quality Indicator/Quality Measure Series - Chronic Care (for Sub-unit)

This report contains the same information as presented in the Resident Quality Indicator/Quality Measure Summary Report; however in this report the information is broken down to present a separate QI/QM on each page. This report series helps to make it easier to view all residents who flagged on a particular QI/QM.

How to Use the Individual Quality Indicator/Quality Measure Series Report
This report can be used to look more closely at an individual QI/QM and see all the residents who flagged on that particular QI/QM. This series of reports could also be used to further investigate clinically linked QI/QMs.

The Resident Listing Report can be run based on three different population bases:

• Resident Listing - Chronic Care
• Resident Listing - Post Acute Care
• Resident Listing - Chronic Care (for Sub-unit)

This report contains a list, sorted either by resident name or resident ID number, of all residents appearing in any of the QI/QM reports including residents whose most recent assessment is an admission assessment. The first column, Resident ID, represents a code that is only used in the database system. This column is not meant to reflect any ID code used by facilities or surveyors. It is included only for reference purposes. Column 2 presents the resident's last name and first name as represented in the Standard Automation system. In columns three and four are the most recent assessment reference date and the associated reason for assessment (AA8a). The fifth and sixth columns represent the assessment date and reason for the previous assessment (that is, the assessment used as the basis for QI/QM incidence calculations that require the most recent previous assessment). Column seven, Discharge date, shows the resident's most recent discharge that occurs on or after the most recent assessment date. Note that discharges occurring before the most recent assessment date are not shown. The final columns reflect resident's room number, birth date, SSN and Medicare number.

How to Use the Resident Listing Report
The primary purpose of this report is to provide more identifying information about residents and the assessments used in the preparation of the QI/QM reports.

The Assessment Summary report can be run based on two different population bases:

• Assessment Summary - Chronic Care
• Assessment Summary - Chronic Care (for Sub-unit)

This report was not designed as a QI/QM report. It is included to provide some aggregate information about the MDS data assessments that occurred during a period of time based on the assessment reference date (MDS field A3a). The intent of this report is to summarize MDS assessments based on the MDS Assessment Reference Date and display this by month and by type of assessment submitted. The first column of the report indicates the month and year. The second column, Unique Residents, is a count of the residents with MDS assessments occurring during the month. Total assessments is the count of accepted assessments with assessment dates falling in the month. The final column, Accepted Assessments by Type, shows the count of assessments by the type of assessment using the MDS field AA8a.

How to Use the Assessment Summary Report
This report can be used to develop a rough understanding of the MDS data flow for a facility.

The Data Submission Summary report can be run based on a single population base:

• Data Submission Summary - Chronic Care

This report was also not designed as a QI/QM report. Rather, it is included to provide some aggregate information about the MDS data submissions that occurred during a period of time. This report summarizes the number of submissions based on the date assessments were submitted. The first column of the report indicates the month and year. The second column shows the number of production (non-test) submissions during the month. The third column, Unique Residents, is a count of the residents appearing in the submissions for the month. Total assessments is the count of assessments accepted during the month. The final column, Accepted Assessments by Type, shows the count of assessments by the type of assessment submitted using the MDS field AA8a.

How to Use the Data Submission Summary Report
The intent of this report is to indicate the number of production submissions by month and by type of assessment submitted.

The Quality Indicator/Quality Measure Graphs report can be run based on two different population bases:

• Facility Quality Indicator/Quality Measure Graphs - Chronic Care
• Facility Quality Indicator/Quality Measure Graphs - Post Acute Care

This report is a visual representation of your QI/QM percentages over time. Each graph shows your population's QI/QM percentage graphed over a given time period. The graphs can either be run by month (going back as far as 24 months) or quarter (going back as far as 16 quarters). The comparison group's averages, as well as the 25th and 75th percentile results are displayed on the same graph, and you can choose to graph some or all of the QI/QMs.

For the 3 regression adjusted QI/QMs (5.2 Residents with catheter, 8.1 Pain and 9.3 Residents whose ability to move around decreased) an extra graph will be provided showing the overall facility average after adjusting for the risk factors specified by CMS. The comparison group average and percentile ranks are also adjusted for risk on these graphs. For more information on the risk adjustment process see the link What's new about QI/QM Reports in the Quality Center.

How to Use the Quality Indicator/Quality Measure Graphs
These graphs can be used to view your QI/QM percentages over time. They can help you to see trends or changes in the QI/QM percentages and evaluate your results against the comparison group percentages.