AAPACN is dedicated to supporting post-acute care nurses provide quality care.

Questions on Quality Measures Answered by AAPACN Nurse Experts – Part Two

On June 14, 2023, the American Association of Post-Acute Care Nursing (AAPACN) hosted the AAPACN 2023 Quality Virtual Conference, a one-day virtual conference that brought together leaders and experts in quality improvement to provide attendees with the information and resources necessary to monitor quality measures and outcomes for improved performance for both skilled nursing facilities (SNFs) and home health agencies (HHAs). For those unable to attend the event on June 14, AAPACN is offering a bundle of the sessions for on-demand learning. Learn more here.

In conjunction with that event, AAPACN asked attendees to submit their questions on Quality Measures (QMs) from any program—MDS 3.0 QMs, Quality Reporting Program (QRP) QMs, Value-Based Purchasing QMs, those that impact Five-Star, or those publicly reported on Nursing Home Compare—to the AAPACN Leading in Care Blog. Six of those questions were answered in Part One of this blog, “6 Questions on Quality Measures Answered by AAPACN Nurse Experts.” Below are the responses to the remaining questions.

Question 7: Quality Measure data is old information. How can I translate this data into actions to improve quality? How long will it be until I see a change reflected in the QMs?

Response from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, AAPACN Curriculum Development Specialist:

Identifying the areas of concern expressed in the Quality Measures (QM) is the first step in moving toward quality improvement. However, before that can be done, you must ensure that the data reflected in the QM is accurate. Inaccurate MDS data can be corrected via a modified assessment and resubmitted to the federal repository. This change will be reflected in the MDS 3.0 QMs in iQIES the following week. Corrections must be completed timely—once data is publicly reported, corrections in iQIES will not change the public data.

If the MDS data is correct, then the facility should conduct a root cause analysis to determine the clinical causes and contributing factors of the quality issues. Once the clinical issues are identified and an action plan is implemented via the facility’s QAA/QAPI process, quality of care should be monitored closely for the desired improvements. Improvement will be reflected in the internal monitoring process and in future MDS completion. MDS assessments should not be completed for the sole purpose of improving QMs, so facilities may not begin to see improvement in the measures until the next assessment is completed. This could be three months or more before a change is seen.

It is important to understand how the individual QMs are calculated, as that will determine how long it will take to see a change in the numbers as well. More information on this can be found in the AAPACN tool, When MDS 3.0 Quality Measures Triggers Start and Stop. It may take up to a year before improvements are reflected in the Five-Star QMs since four quarters of data are used with a delay in reporting.

Question 8: How can I explain to owners/leaders not in the field that the Quality Measure data doesn’t necessarily reflect our current progress? For example, we are working to reduce readmissions/rehospitalizations, but the QM data on Care Compare shows a different picture than what we have currently accomplished.

Response from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, AAPACN Curriculum Development Specialist:

It is important for leadership to understand that the data that is publicly available is old. Data posted on the Care Compare website as of Aug. 2, 2023, reflects data from Jan. 1, 2022, to Dec. 31, 2022, for the short-stay rehospitalization measure, Percent of Short-Stay Residents Who Were Re-Hospitalized After a Nursing Home Admission—a nine-month lag time. The Discharge to Community measure and Potentially Preventable 30-Day Post Discharge Readmission measure data is from July 1, 2019, to Dec. 31, 2019, and July 1, 2020, to June 30, 2021, a two-year lag time with almost four-year-old data reflected. The current QM collection periods for the publicly reported data can be found here. It is important to share this information with leadership to help them to understand that changes seen at the facility level will not be reflected publicly for quite some time. It is important to understand what the facility-specific electronic health record can provide regarding real-time data on Quality Measures. These internal reports as well as reports in iQIES, which both show more current data, can be compared with the publicly reported data to show improvements to facility leadership.

Additional Quality Measure Education and Resources from AAPACN: