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Improving the Percent of Residents Who Have/Had a Catheter Inserted in their Bladder Long Stay Quality Measure (QM)
How Is This QM Triggered?
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Objectives
• Become familiar with the Quality Measure specifications
• Understand how MDS coding triggers the Quality Measure
• Verify accuracy of Quality Measure Score
• Tips for Improvement
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Catheter Quality Measure
This measure is used in:
• Nursing Home Compare
• Five Star Rating
• CASPER Quality Measure Reports
• Nursing Home Quality Care Collaborative Composite Measure Score
• Reviewed in Annual Survey process
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• This measure reports the percentage of
residents who have had an indwelling
catheter at any time during the last seven
days
• What qualifies the resident as long stay =
number of cumulative days in the facility
– Refers to residents who are in the facility for 101
or more cumulative days
– Days out of the facility are not calculated in the
cumulative day count
Catheter Quality Measure
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Critical Resources:
Methodology and scoring for all 3 Domains
Identifies how each QM is triggered!
Instructs on RAI coding timing and reporting
January 2017
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Catheter Definition
Indwelling catheter: A catheter maintained in the bladder for the purpose of continuous drainage of urine.
• Suprapubic catheter: An indwelling catheter placed by a urologist directly into the bladder through the abdomen, usually when there is an obstruction of urine flow through the urethra.
• Nephrostomy tube: A catheter inserted through the skin into the kidney in individuals with an abnormality of the ureter or bladder.
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CASPER Facility Level Quality Measure Report
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CASPER Resident Level Quality Measure Report
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Catheter Quality Measures Users Manual
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QM Denominator # Of Residents Potentially Impacted by QM
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QM Numerator # Of Residents Potentially Impacted by QM
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QM Exclusions Conditions that Exclude from Both Numerator and Denominator
4 Exclusions:
1= Target Assessment is Admission Assessment 2= Target Assessment has missing
catheter status
3= Neurogenic Bladder 4= Obstructive uropathy
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Catheter Quality Measures Users Manual
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Catheter Numerator
Source: RAI
Manual
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Physical Restraint QM Impacts Five Star Rating
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Core Prevention Catheter Use
CDC Core Prevention Strategy:
• Insert catheters only for appropriate indications:
– acute urinary retention + bladder outlet obstruction
– assist with healing open sacral or perineal wounds
• Leave catheters in place only as long as needed – remove catheters ASAP
• Avoid use
– in elderly,
– Impaired immunity
– Avoid use for management of incontinence
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Consider Alternatives to Indwelling Catheters
• Intermittent catheterization
• Bladder Ultrasound Scanners
• External Catheters
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Process Considerations
• Those admitted/readmitted with catheter- Do you monitor/verify for appropriate diagnosis?
• How does the facility monitor the pressure ulcer healing process if an indwelling catheter is used to maintain skin integrity or comfort?
• Avoidance of UTI – Staff proficiency in perineal-/catheter care
– Handwashing
– Hydration
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Improvement/Next Steps
1. Review your CASPER data for all residents coded on the MDS with a catheter
2. Review MDS indwelling catheter definition
3. Verify coding accuracy reviewing QM numerator, denominator and exclusions from the Quality Measures Specification in the MDS 3.0 Quality Measures Users Manual
4. Formalize and implement the required systematic evaluation for catheter use
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Resources
MDS 3.0 RAI Manual https://downloads.cms.gov/files/MDS-30-RAI-Manual-V114-October-2016.pdf
Design for Nursing Home Compare Five Star Quality Rating System Technical Users Guide https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/usersguide.pdf
MDS 3.0 Quality Users Manual https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c07.pdf
Survey and Enforcement Process for SNF https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c07.pdf
NNHQCC Change Package https://www.nhqualitycampaign.org/files/NH_ChangePackage_v2.0_03-26-2015_Final.pdf
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Contact Information
This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QIN-02/23/17-02/23/17-11971
• Kari Caughron, RN
– Quality Improvement Facilitator
– 515-267-6227
• Larpie Castro
– Senior Quality Improvement Facilitator
– 630-928-5812
• Lisa Bridwell
– Senior Quality Improvement Facilitator
– lisa.bridwell@area-d. hcqis.org
– 630-928-5831
• Nell Griffin
– Quality Improvement Facilitator
– nell.griffin@area-d. hcqis.org
– 630-928-5813
Linda Savage
– Program Specialist
– 303-513-2323
