Composite Score Tutorial

David L. Johnson, NHA RAC-CT

IPRO

Senior Quality Improvement Specialist

Goals for this presentation…

• To provide a general overview of the Composite

Score

• To provide a recommended step-by-step process to

collect and analyze your own facility’s score.

• To establish the Composite Score as an identified

source of data and information for use in your QAPI

process to effectively collect, analyze, compare and

display your data to identify improvement

opportunities and assess your performance.

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Element 3 in the 5 Elements in QAPI…

• Feedback, Data Systems and Monitoring

“The facility puts in place systems to monitor care and

services, drawing data from multiple sources.”

Once information has been gathered, you need to organize it in a

way that helps your team understand what is happening.

The effective use of data will ensure that decisions are being

made based on “fact” and not on an assumption of the truth.

QAPI Teams and Performance Improvement Project (PIP) Teams

need data to ensure they are targeting the right areas.

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Resources for this presentation…

• CASPER Reporting MDS Provider User’s Guide

(Certification And Survey Provider Enhanced Reports)

• The CMS QAPI Guide: What You Need to Know / A

Companion to QAPI at a Glance

• MDS 3.0 Quality Measures User’s Manual

www.nursinghomes.ipro.org

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This material was prepared by the Atlantic Quality Innovation Network/IPRO, the Medicare Quality Innovation Network

Quality Improvement Organization for New York State, South Carolina, and the District of Columbia, 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. 11SOW-AQINNY-TskC.2-15-15

Some Basic Composite Score Facts…

• The data used to calculate your facility’s Composite

Score comes directly from MDS records that are

submitted from your facility.

• The Composite Score is comprised of 13 NQF-

endorsed long-stay quality measures.

• Though not all 13 measures used to calculate your

Composite Score are currently available in the

CASPER system, 11 of those measures are available

from CASPER to review, analyze and monitor in “real

time”.

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Where did the Composite Score come from?

The NNHQCC (National Nursing Home Quality Care

Collaborative), led by the Centers for Medicare & Medicaid

Services (CMS) and Quality Improvement Organizations

(QIOs), ran from February 2013 through July 2014. There

were approximately 5,000 nursing homes participating

across the country.

The NNHQCC worked to instill quality and performance

improvement practices, eliminate healthcare acquired

conditions, and dramatically improve resident satisfaction

through the achievement of a rate of 6 or less using the

NNHQCC quality composite measure.

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Where did the Composite Score come from? (continued…)

As with the Quality Measures –

“the lower the score, the better”.

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(Total Numerators from 13 NQF- Endorsed QMs)

----------------------------------------------------------------------- = x 100 = Composite Score

(Total Denominators from 13 NQF- Endorsed QMs)

What is included in the Composite Score…

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• The Composite Score is comprised of thirteen NQF-

endorsed long-stay quality measures

• Of those 13 long-stay quality measures

• 11 “Clinical” Quality Measures

• 2 Vaccine Quality Measures (Flu and Pneumococcal)*

*The two vaccination measures are “directionally opposite” and should

be reversed in the calculation. This is done by subtracting the

numerator from the denominator to obtain a “new” numerator. By

keeping the measure directions consistent, the composite score can be

interpreted as “the lower, the better”.

Which long-stay “clinical” measures are included in the Composite Score…

• Residents who self-report moderate to severe pain

• High-risk residents with a pressure ulcer

• Residents who are physically restrained

• Residents who fall with major injury

• Residents receiving an antipsychotic medication

• Residents with depressive symptoms

• Residents with a UTI

• Residents with a catheter inserted or left in bladder

• Low-risk residents with loss of the bowel or bladder

• Residents who lose too much weight

• Residents who need increased help with ADLs

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Composite Score and CASPER Data…

• CASPER data includes 11 of the 13 QMs included in

the Composite Score calculation

• The 2 vaccination measures, though reported on NHC,

are currently not part of the reports available in the

CASPER system.

Our recommendation is that you monitor, analyze and

track the 11 “clinical” quality measures that are available

in the CASPER data system.

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Facility Level Quality Measure Report…

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Example of “Clinical Composite Score” (11 QMs)…

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(Total Numerators from 11 QMs) 158

--------------------------------------------------------------- = .1296 x 100 = 12.96 (Total Denominators from 11 QMs) 1219

The Composite Score is calculated using a methodology based on the opportunity model.

The Denominator represents the # of opportunities to provide or reflect quality care.

The Numerator represents the number of times an opportunity was missed.

Vaccination Impact on Composite Score…

Because the 2 vaccination measures are “directionally

opposite” from the other quality measures…

• When the vaccination statistics are “reversed” and

included in the overall calculation for the Composite

Score-

• The result, in most cases... is a “softening”, or lowering, of

the composite score.

• This variation may vary from facility to facility.

• Upon request, the IPRO Nursing Home Team can provide

you with some historical data on the impact of your specific

facility’s vaccination “reversal”.

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Example of “Vaccination” impact…

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(Total Num. from 11 QMs) 158 + 10 = 168

--------------------------------------------------------------- = .1137 x 100 = 11.37 (Total Den. from 11 QMs) 1219 + 258 = 1477

For this example-

129 long-stay residents for EACH vaccination measure

Assume 5 out of 129 did not trigger for either vaccinations QM (96% Vaccination QMs)

“Clinical” Composite – 12.96

“Clinical” Composite plus Vaccination impact - 11.37

Difference - positive “softening” of 1.59 percentage points

“Clinical” Composite Calculator…

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“Clinical” Composite Calculator…

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“Clinical” Composite Calculator…

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“Clinical” Composite Calculator…

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Expand your knowledge and analysis…

• Consider both “sides” of each equation

• Numerator- Those residents “triggering”, or having the

condition.

• Denominator- All residents who could have had the

condition.

Any change in either part of the equation will change the result.

The analysis of your data must involve

BOTH the “inclusions” and the “exclusions” (if any)

for each Quality Measure.

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“Clinical” Composite Calculator…

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Quality Measure Specifications…

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Full

description

of specific

Quality

Measure

Quality Measure Specifications…

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Measure

Specifications

to include

“Numerator”,

“Denominator”,

and any

“Exclusions”

applicable to the

calculation of

the specific

Quality Measure

Quality Measure Specifications…

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Any “Covariates”

applicable to the

calculation of the

specific Quality

Measure.

There is only a subset

of 3 quality measures

that are

“risk adjusted”…

Long Stay Pain,

Long Stay Catheter in

Bladder, & Short Stay

Pressure Ulcers.

Quality Measure Specifications…

Offer “item specific” information directly tied to the items on

the MDS 3.0…..

when paired with the most current version of the

RAI Manual…

that “drill down” process provides direction in the specific

coding requirements, guidance and expectations tied to

each detailed MDS item

impacting the specific quality measure.

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Action Steps…

Ensure that key team members are fully educated in the

sources, adjustments and calculations of your CASPER data

and how they impact your facility’s Composite Score.

Develop a data collection plan, including who will collect

the data, who will review it, the frequency of the collection

and reporting, etc.

Determine focused areas of investigation based on your “real

time” data review, analysis and continuous monitoring of both

your CASPER data and the resulting Composite Score.

Charter appropriate teams to investigate, analyze,

recommend, trial and evaluate results for specific areas

identified through your consistent monitoring.

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For more information

Pauline Kinney, RN, MA, LNHA, RAC-CT

Director, Healthcare Quality Improvement

Tel: (516) 209-5402

pauline.kinney@area-i.hcqis.org

Maureen Valvo, RN, BSN, RAC-CT Sr. Quality Improvement Specialist

Tel: (516) 209-5308

maureen.valvo@area-i.hcqis.org

IPRO CORPORATE HEADQUARTERS

1979 Marcus Avenue

Lake Success, NY 11042-1002

IPRO REGIONAL OFFICE

20 Corporate Woods Boulevard

Albany, NY 12211-2370

www.atlanticquality.org

David L. Johnson, NHA, RAC-CT

Sr. Quality Improvement Specialist

Tel: (518) 320-3516

david.johnson@area-i.hcqis.org

Dan Yuricic, MA

Sr. Quality Improvement Specialist

Tel: (516) 209-5458

danny.yuricic@area-i.hcqis.org

Template 8/12/2014

IPRO Nursing Home Team

Pauline Dave Dan Maureen

Kinney Johnson Yuricic Valvo