3 Quality Measures LeadingAge KS Members Should Pay Attention To

It is LeadingAge Kansas’ mission to assist members in providing outstanding services and supports to older Kansans in a place they call home through advocacy, education and networking. Through our collaboration with LeadingAge New York Technology Solutions, LeadingAge Kansas has identified three clinical outcome measures where Kansas nonprofits (NP’s) are significantly underperforming their peer groups’ bench marks;

1. Depression (Percent of Residents Who Have Depressive Symptoms),
2. Falls (Percent of Residents Who Experience One or More Falls With Major Injury), and
3. UTI (Percent of Residents With a Urinary Tract Infection).

These three clinical outcome measures are of concern to CMS as these measures may be used to ascertain a provider’s compliance with new survey guidelines. The depression measure can be used to gauge a provider’s resident voice/choice program because increasing a resident’s participation empowers the resident and can decrease symptoms associated with mood disorders. The falls measure calculates resident level actual harm. One of CMS’ goals is to reduce harm. The UTI measure can determine a provider’s progress in its Infection Control/Antibiotic Stewardship program.

In the bar graph above, Kansas Not for Profit Nursing Homes (Kansas NP’s) – blue bar, is compared to 2 peer groups: National Non Profit Nursing Homes (National NP’s) – orange bar and Region (Not for Profit Nursing Homes from the following states: Kansas, Iowa, Nebraska and Missouri) – gray bar thus providing a snapshot of Kansas NP’s relative performance against bench marks. The vertical axis is the rate and the horizontal axis is the quality measure. Kansas NP’s rate is significantly higher than the National NP’s rate, 30-42% higher in falls and depression, and 44% higher in UTI’s. Kansas NP’s are less significantly but still higher than the Region at 15-20% higher in all three measures.

This analysis highlights the three long stay clinical outcome measures that Kansas is significantly underperforming in. At first glance these outcomes may seem unrelated but upon further study there is a common thread. Dangerous Urinary Tract Infections can lead to falls in nursing home residents. Illness, pain and debilitation often accompany both UTI’s and major injury; conditions which result in residents suffering from mood disorders and possibly depression.

Root cause analysis can help your organization identify a root cause of poor performance and therefore; target precious resources to a program that may well improve all three measures simultaneously. Here are some practical tools for you and your team on root cause analysis:

• Root Cause Analysis Toolkit for Long Term Care https://www.stratishealth.org/providers/rca-toolkit/
• 16 minute video and PowerPoint (below) on root cause analysis in long term care and why it is valuable https://www.youtube.com/watch?v=Ju0yajsb3qU

Examine your Restorative Nursing Program because it is  critical to these three outcome measures. A great restorative nursing program can help improve a residents’ continence, strength, mobility, and independence and consequently improve the residents’ feelings of self-worth; effectively avoiding UTI’s, preventing falls and averting depression.

Article written for LeadingAge Kansas by Susan Chenail RN, CCM, RAC-CT, Senior Quality Improvement Analyst, LeadingAge New York

Quality Metrics Analysis Manager was utilized to perform the analyses contained in this report. (Latest extract date from CMS; 1/1/18) The MDS based quality measures depicted in this report are based on the following 4 quarters of data: 4^th quarter (Oct., Nov., Dec.) of 2016 and 1^st, 2^nd, 3^rd quarters (Jan., through Sept.) of 2017.