National nursing home quality measures: 34 and counting

It isn’t easy to sort out the differences among the quality measures (QMs) described in the QM manual, the Certification and Survey Provider Enhanced Reporting (CASPER) system, Nursing Home Compare, the Five-Star nursing home rating system and the annual survey process. Taken all together, 34 QMs are detailed in these sources. Granted, 16 of them relate to immunization rates, and many QMs are duplicated in the short-stay and long-stay calculations. Nonetheless, it is critical for facility leaders to understand the QMs and how they are used for survey outcomes, Five-Star ratings and public awareness.

The MDS 3.0 Quality Measures User’s Manual details 32 Quality Measures: 10 short-stay, 18 long-stay and four survey-only measures. Of the 32 QMs, 16 are available in the CASPER online system for the surveyors to use during the facility’s annual survey. Facility staff can locate these QM calculations and reports where MDSs are submitted to the QIES ASAP system via the Centers for Medicare & Medicaid Services (CMS) welcome screen.

Nursing Home Compare publishes 18 QMs for the public to view. Again, 16 of them are a subset of the 32 detailed in the QM User’s Manual, but CMS has added two additional QMs for the public to view. They are incidence of antipsychotic use (short-stay) and prevalence of antipsychotic use (long-stay). The specifications for the antipsychotic measures are currently not detailed in the QM manual, but they are described in a memo located on the Five-Star rating website.

The Five-Star nursing home rating system was revised in July. Of the 18 QMs listed on Nursing Home Compare, nine of them feed into the Five-Star rating system. The Five-Star rating system was developed to provide residents and their families with an easy way to understand assessment of nursing home quality.

Knowing that the QMs are used by surveyors and the public to evaluate your facility’s care outcomes should convince you to give high priority to understanding the details of the QMs. Download your reports from the CASPER system, in addition to looking at your rates posted in Nursing Home Compare. The posted QM rates in these different systems will not match exactly because each of the reporting systems uses different timing and reporting periods.

Once you view your QM scores, begin the process of proactively addressing any negative outcomes. Low QM percentile rankings indicate potential problems, but to determine whether they are actual problems, the outcomes must be evaluated and verified as care issues. Identify the measure you are going to investigate and then pull the corresponding "resident level quality measure report" in the CASPER system. This resident-level detailed report will assist you in determining which residents were selected for the QM reports. Select a sample of residents affected by the measure and conduct a thorough audit of the medical record and MDSs. First, verify that the MDS coding was accurate. Then conduct a thorough investigation of the medical record for poor care outcomes for the specific resident.

After auditing a number of resident records, potential or actual care system problems may begin to emerge. Use your quality assurance committee to dig deeper into the care system issue as a team to learn what may be causing the breakdown in outcomes and to enhance opportunities for creative solutions.

At the beginning of this process, conducting an evaluation of your QM ranking and verifying care system problems is a reactive process. Make it a facility goal to look ahead and work toward being proactive about enhancing quality-of-care systems. Continuous quality improvement planning will help you improve and maintain your QM scores.

To download a complete list of the QMs and to learn more, visit these websites:

Judi Kulus is vice president of curriculum development, American Association of Nurse Assessment Coordination. She can be reached at


Topics: Articles , Facility management , Regulatory Compliance