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"Accessing & Understanding QI/QM Reports"
Teleconference, presented by Danielle Branum, MDS/OASIS
Automation Coordinator - 08/09/07
As of July 2005 the publicly reported nursing home
quality measures (QMs) will be available for surveyors
and facilities in the form of a consolidated QI/QM
report. This consolidated report will allow for nursing
facilities to have more up-to-date information on the
QMs to help guide their quality improvement efforts. It
is important to remember that the QM values being
reported on Nursing Home Compare will not match the
values on the facilities' consolidated CHSRA QI/QM
reports. There are several reasons for this including
potentially assessing different time frames, timing of
updates, selection periods, and differences in risk
adjustment:
- Timing - NHC is run once a quarter while the statistics that are
reported on the MDS QI/QM System are updated weekly. It is therefore
likely that the assessment database has changed between the time the
NHC statistics were computed and the time the MDS QI/QM statistics
were computed. The MDS QI/QM statistics will reflect any
assessments, corrections, and inactivations that were submitted
since the NHC statistics were computed.
- Selection Periods - Every QM is based upon the selection of a
target assessment. For NHC, the target assessment must have a
reference date within the most recent 3 months for chronic care (CC)
measures and the most recent 6 months for post-acute (PAC) measures.
On the MDS QI/QM Reports, you are allowed to customize the length of
the selection period (by adjusting the beginning and ending date of
the report). The default period is 6 months for these reports. If
the selection periods you select are different from those used for
NHC, the results may not match.
- Risk Adjustment - Some of the QMs use risk adjustment. These
measures have entries in the “adjusted percent” columns on the MDS
QI/QM Facility Quality Measure/Indicator Report. These adjusted
percentages may not match the percentages reported on NHC because of
the way the risk adjustment calculations are performed. One of the
factors that is used in the risk adjustment calculations is the
national average for the QM at the time of calculation. Since the
calculations are usually performed at different times for the two
systems (see #1 above), the national means may differ and the
percentages may be different on the two sets of reports.
- Minimum Sample Size - NHC does not report a measure for a
facility if the denominator for that measure is less than 30 for
chronic care measures or less than 20 for post-acute care measures.
The MDS QI/QM Reports have no such criteria – statistics are
reported regardless of the size of the denominators.
The Colorado Foundation for Medical Care (CFMC), the Medicare quality improvement organization for Colorado, prepared this material under
contract with the Centers for Medicare & Medicaid Services (CMS), an
agency of the U.S. Department of Health and Human Services. The contents
do not necessarily reflect CMS Policy.
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