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NNHQCC Quality Measure Composite Score Cheat Sheet (DRAFT) by [deleted]

The NNHQCC Quality Measure Composite Score

This is a draft cheat sheet. It is a work in progress and is not finished yet.


As the Medicare Quality Innovation Networ­k-Q­uality Improv­ement Organi­zation (QIN-QIO), Health Services Advisory Group (HSAG) is funded by the Centers for Medicare & Medicaid Services (CMS) to spearhead the NNHQCC in Arizona, Califo­rnia, Florida, and Ohio. The NNHQCC is a five-year project that runs through July 31, 2019. The NNHQCC framework focuses on supporting the adoption of Quality Assurance & Perfor­mance Improv­ement through collab­orative learning and action networks (e.g., face-t­o-face meetings, online trainings, conference calls, and webinars)

Measuring Collab­orative Success

Partic­ipating nursing homes, focusing on processes that improve their system, measure on individual tests of change. They will look at their Plan-D­o-S­tud­y-Act (PDSA) improv­ement cycle results, their clinical outcome measures, and their composite score

The NNHQCC Quality Measure Composite Score

The composite score is composed of 13 long-stay quality measures that represent larger systems within the long-term care setting:
1. Percent of residents with one or more falls with major injury
2. Percent of residents with a urinary tract infection
3. Percent of residents who self-r­eport moderate to severe pain
4. Percent of high-risk residents with pressure ulcer
5. Percent of low-risk residents with loss of bowels or bladder
6. Percent of residents with catheter inserted or left in bladder
7. Percent of residents physically restrained
8. Percent of residents whose need for help with activities of daily living has increased
9. Percent of residents who lose too much weight
10. Percent of residents who have depressive symptoms
11. Percent of residents who received antips­ychotic medica­tions
12. Percent of residents assessed and a ppropr­iately given flu vaccine*
13.Percent of residents assessed and approp­riately given Pneumo­coccal vaccine*
*The direction of the two vaccin­ation measures should be reversed because they are direct­ionally opposite of the other measures. This is done by subtra­cting the numerator from the denomi­nator to obtain a β€œnew” numerator. By keeping all measure directions consis­tent, the composite score can be interp­reted as: the lower, the better.

Measuring the Success

Instru­ctions for Calcul­ating Your Composite Score

Should you choose to calculate your own composite score for qualit­y-i­mpr­ovement purposes, it is important to know that the flu and pneumo­coccal measures are not available through the Quality Improv­ement and Evaluation Service (QIES) CASPER data system. Therefore the instru­ctions below include the steps to calculate a modified composite score for tracking purposes. To calculate your composite measure, excluding the immuni­zation measures for monitoring purposes only, do the following:

Step 1. Run your facility quality measures reports in CASPER for a six-month time period, for example, from July 1 through December 31, 2015.
Step 2. Sum the numerators for measures 1–11 above. This will be your composite numerator. For example, numerator = 76
Step 3. Sum the denomi­nators for measures 1–11 above. This will be your composite denomi­nator. For example, denomi­nator = 918
Step 4. Divide the composite numerator by the composite denomi­nator. For example, numera­tor­/de­nom­inator = 76/918 = 0.08
Step 5. Multiply by 100. For example, 0.08 X 100 = 8.0
This measure is intended for the sole purpose of measuring progress in the NNHQCC. It is not intended to replace any existing CMS measures or scores such as the Five Star Rating System. These measures were chosen for the composite because timely data are available for measuring progress in this fast-paced collab­ora­tive. QIOs have access to the qualit­y-m­easure data necessary to calculate composite scores for nursing homes partic­ipating in the collab­orative in their state.