Toward a National Health Information Infrastructure: A Key Strategy for Improving Quality in Long-Term Care. APPENDIX D. Examples of MDS-Derived Quality Measures

Percent of Residents with Pressure Sores with Additional Level of Risk Adjustments
(A QM for Long-Stay Residents)
Numerator
  • Number of residents with pressure ulcers (stage 1-4) on full or quarterly assessment (M2A > 0 or I3a-e = 707.0)
Denominator
  • All residents with valid full (AA8a = 01, 02, 03, 04) or quarterly assessment (AA8a = 05 10)
  • Exclusions: Most recent assessment is the admission assessment (AA8a = 01); the QM is not triggered (resident is not included numerator) AND the value of M2a is missing on the target assessment.
Resident is a facility with a chronic care sample size =0 (i.e., over the last 12 months no residents with a non-PPS assessment - AA8a= 01 and AA8b=blank or 6)

Facility Admission Profile
Considers prevalence of stage 1-4 PU (M2a>0 OR I3a-e=707.0 among admissions (AA8a=01) occurring over the previous 12 months

Numerator: admission assessments (AA8a=01) w/ M2A.0 OR I3a-e=707.0
Denominator: all admission assessments (AA8a=01)
Exclusions: admission assessments (AA8a=01) that do not satisfy the numerator conditions AND have missing data on M2a.

 

Percent of Short-Stay Residents with Pain
(A QM for Short-Stay Residents)
Numerator Number of residents who experience moderate pain at least daily (J2a = 2 and J2b = 2) OR horrible excruciating pain at any freqency (J2b = 3) as noted on the SNF PPS 14 day
Denominator
  • All residents with valid SNF PPS 14 day assessment (AA8b = 7)
  • Exclusions: J2a or J2b missing from SNF PPS 14 day assessment; J2a or J2b inconsistent on the SNF PPS 14 day assessment (e.g., coding pain frequency as "no pain" while simultaneously coding intensity of pain as "moderate"); resident is in a facility with a post-acute care sample size =0 (i.e., SNF PPS 5 day assessment AA8b=1 over the last 12 months).
Uses SNF PPS 14 day assessment (AA8b=7) with valid preceding 5 day SNF PPS assessment (AA8b=1)

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