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Running From Fire to Fire on QMs? Develop a Systematic Approach

Even with the implementation of other quality programs over the past few years, the Nursing Home Quality Initiative (NHQI) quality measures (QMs) remain the core public-facing quality thermometer of long-term care. Taking the time to improve these QMs may seem like a “wish list” activity when staff are stretched thin. “However, you are investing in your facility’s future—and you want to make that investment as efficiently and effectively as possible by using a systematic approach,” says Faith Carini-Graves, BSN, RN, RAC-CT, director of skill development for MDS Consultants in Medina, NY.

“Better QMs can improve your ratings in the Five-Star Quality Rating System and help you deliver better care to residents, resulting in better resident outcomes and better survey outcomes,” says Carini-Graves, who will co-present the session “Ways to Improve Quality Measures Without Breaking a Sweat” at Connected | Together, the April 12 – 14 AAPACN 2022 Conference in Las Vegas, NV. “Potential residents and their families also will be looking at your data on Care Compare.”

Further, QM enhancement can be good for facility-based outcomes, such as reimbursement, says Carini-Graves. “For example, improving the QMs can help keep your residents from being readmitted to the hospital. That’s critical to success in the current version of the pay-for-performance Skilled Nursing Facility Value-Based Purchasing program (SNF VBP).”

SNF VBP future heightens urgency

Going forward, the SNF VBP will only grow more important, notes Carini-Graves. “At some point, the Centers for Medicare & Medicaid Services (CMS) plans to add up to nine additional measures to the SNF VBP, and certain NHQI QMs are among the measures currently under consideration, which would directly tie the two programs together.”

The Fiscal Year (FY) 2022 Skilled Nursing Facility Prospective Payment System (SNF PPS) final rule reveals that the following information from Care Compare, including five MDS-based QMs, could be incorporated into the expanded SNF VBP:

Source: MDS
  • Percent of Residents Experiencing One or More Falls With Major Injury (Long-Stay)
  • Percent of High-Risk Residents With Pressure Ulcers (Long-Stay)
  • Percent of Residents Whose Ability to Move Independently Worsened (Long-Stay)
  • Percent of Residents Whose Need for Help With Activities of Daily Living Has Increased (Long-Stay)
  • Percent of Residents Who Got an Antipsychotic Medication (Long-Stay)  

  • Source: Claims
  • Number of Hospitalizations per 1,000 Long-Stay Resident Days (Long-Stay)  

  • Source: Payroll-Based Journal (PBJ)  
  • Nurse staffing hours per resident day: Registered Nurse (RN) hours per resident per day; Total nurse staffing (including RN, licensed practical nurse (LPN), and nurse aide) hours per resident per day. CMS also indicates an interest in including staff turnover measures in the SNF VBP. The agency began posting staff turnover measures on Care Compare in January, and these measures will be added to Five-Star in July. For more information, see Quality, Safety, and Oversight (QSO) memo QSO-22-08-NH and the Five-Star Quality Rating System Technical Users’ Guide.
  • Note: Providers should expect to see the SNF VBP expansion happen sooner rather than later. CMS anticipates holding a technical expert panel (TEP) in early May, as well as potential follow-up TEP meetings over the summer and fall, to discuss the scoring methodology for the SNF VBP expansion. This will follow on the heels of another TEP that was scheduled to meet in February and March to review measurement gaps and measure development priorities for the SNF VBP.

    What is a systematic approach—and why use it?

    The key to maximizing QM improvement is a systematic approach, stresses Carini-Graves. “A systematic approach is plan-based and consistent. You have to look at the QMs, start where the need is the greatest, and create a good, solid plan of the actions that you will initiate—a plan that involves multiple levels of staff.”

    So, it’s important to target each facility’s problems or hot spots, explains Carini-Graves. “But, before you start running toward a hot spot to put out the fire, you have to consider everything from a global perspective. You want to take a minute to think about it and plan out your steps for improving the QMs.”

    Using a systematic approach will not only help providers prioritize and evaluate QMs, it also can help them multiply gains, says Carini-Graves. “Many QMs are interconnected. By planning and developing the right systematic approach, you can achieve a trickle-down effect where improving one QM also will start to improve other QMs. In addition, you can improve many outcomes at the same time as well.”

    A systematic approach also may help providers reap time rewards, says Carini-Graves. “It typically takes less time to implement than you think. In addition, the return on investment in terms of time savings could be beneficial in the long run. You may actually save time and free up your staff to focus on additional quality initiatives because they will spend less time, for example, caring for residents with pressure ulcers or urinary tract infections (UTIs), or sending residents out to the hospital.”

    The rules of the road

    Key elements of a systematic approach include the following, according to Carini-Graves:

    • Identify and evaluate problem areas. “You need to understand the QM process and what exactly is triggering a QM,” says Carini-Graves. “The first component of a strong QM evaluation is using real-time data. Sometimes, this may mean reviewing meeting notes and actual nursing documentation rather than looking at older MDS coding.”

      This evaluation should include obtaining feedback from the staff, as well as from residents who are able to give their feedback, adds Carini-Graves. “They are all part of the team too. For example, if you are dealing with decreased mobility, the residents themselves may have good ideas about how they are best motivated to do activities and move around.”
    • Develop and implement a plan based upon the information that the team has gathered. “Team champions can help drive implementation, and you may want to identify different staff members who specialize in specific areas to be the team champion for related QMs,” says Carini-Graves. “However, while one person can head up the project and lead the way, you still want to have a full team approach—with a plan that is well-communicated to the team and understood by all team members. So, education is crucial.”
    • Put an auditing and monitoring process in place. “You need to choose a time frame for review and then assess whether the interventions you have implemented are successful within that time frame. It’s important to evaluate your progress using real-time data in this stage as well,” says Carini-Graves. “If you aren’t on the right track, you have to regroup. New interventions or additional staff education can be part of that.”

      Once monitoring shows that the QMs are improved, providers need to change their focus, adds Carini-Graves. “You don’t stop. Instead, you shift to keeping them good and constantly staying up-to-date on current evidence and best practices.”

    The goal of the conference session is to break down these components and other parts of a systematic approach to provide specific, practical steps for improvement, says Carini-Graves. “We want to ensure that attendees have a toolbox of very tangible resources that can help even high-performing nursing homes achieve more consistent results.”

    To get the most out of the session, attendees may want to consider taking a few minutes to prepare some tailored questions, adds Carini-Graves. “If you meet with your team to assess your current QM issues and trends or even just download and review your QM reports beforehand, then you can ask us questions that will whittle down our process to what you can apply in your facility.”

    Note: Carini-Graves will co-present with Linda Winston, RN, MSN, BS, RAC-CT, DNS-MT, QCP-MT. To find their Wednesday, April 13 session on the conference schedule and make plans to attend, download the conference brochure here.

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