Understanding and Using
The Composite Score
March 25, 2014
Objectives
• Understand the composite measure.
• Assess the progress of the National
Nursing Home Quality Care Collaborative
(NNHQCC) and the Virginia Nursing
Home Quality Care Learning
Network using the composite score.
• Learn how to use the composite score to
impact individual quality improvement
performance and projects.
Polling Question
Do you use data to help identify and
monitor quality improvement projects?
National Nursing Home Quality Care
Collaborative (NNHQC)
Aim Statement
The National Nursing Home Quality Care Collaborative
and its partners seek to ensure that every nursing home
resident receives the highest quality of care. Specifically,
the Collaborative will strive to instill quality and
performance improvement practices, eliminate
healthcare acquired conditions, and dramatically
Improve resident satisfaction by July 31, 2014.
The Virginia Nursing Home Quality
Care Learning Network
• Aligns national nursing home quality initiatives and
partnerships
–
–
–
–
Partnership for Patients
Advancing Excellence in America’s Nursing Homes Campaign
The Partnership to Improve Dementia Care
Quality Assurance and Performance Improvement (QAPI)
• Support the development of strategies for overall quality
• Identify opportunities for improvement
• Address gaps in systems through planned interventions
Virginia Nursing Home Quality Care
Learning Network
101 Facilities
The Virginia Nursing Home Quality
Care Learning Network
National Collaborative &
Virginia Learning Network
Topics
Virginia Learning Network
Focus Topics
Staff Stability
Pressure Ulcers
Consistent Assignment
Clostridium difficile
Antipsychotic Medication
Avoidable Hospitalizations
NNQCC and Learning Network
Composite Score Goal
The NNHQCC and the Virginia Nursing Home
Quality Care Learning Network will strive 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 better using the composite
score measure by July 31, 2014.
Measuring NNQCC and Learning
Network Success: The Composite Score
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Percent of residents with one or more falls with major injury
Percent of residents with a UTI
Percent of residents who self-report moderate to severe pain
Percent of high-risk residents with pressure ulcers
Percent of low-risk residents with loss of bowels or bladder
Percent of residents with catheter inserted or left in bladder
Percent of residents physically restrained
Percent of resident whose need for help with ADL has increased
Percent of residents who lose too much weight
Percent of residents who have depressive symptoms
Percent of residents who received antipsychotic medications
Percent of residents assessed and appropriately given flu vaccine
Percent of residents assessed and appropriately given
Pneumococcal vaccine
Key Information
• The composite score is calculated by:
– Summing the 13 measure numerators to obtain the composite numerator,
summing the 13 measure denominators to obtain the composite denominator,
then dividing the composite numerator by the composite denominator and
multiplying by 100.
• Rolling six months
– January 2013 data includes QM data from August 2012 – January 2013
• The direction of the two vaccination measures are reversed because
normally they are directionally opposite of the other measures.
• “6 or better” is interpreted as “6 or less”
• This measure is intended for the sole purpose of measuring progress in
the NNHQCC and Learning Network
– It is not intended to replace any existing CMS measures or
scores such as the Five Star Rating System.
NNQCC Composite Score Data
NNHQCC Composite Score Data
Learning Network Composite Score Data
Statewide Composite Scoring
11
State: Relative Improvement Rate (RIR) = -.39
Learning Network: RIR = 7.41
10.5
10
9.5
9
jan13
feb13
mar13
apr13
may13
jun13
jul13
aug13
sep13
oct13
nov13
dec13
State
9.93
9.84
9.69
9.63
9.55
9.51
9.55
9.55
9.83
10.49
10.4
9.97
LAN
10.24
10.21
10.08
10.04
9.93
9.95
9.86
9.8
10.06
10.67
10.49
10.09
Learning Network Composite Score Data
Statewide Composite Scoring
without Influenza and Pneumococcal measures
10.8
10.6
State: RIR = 5.92
Learning Network : RIR = 7.41
10.4
10.2
10
9.8
9.6
jan13
feb13
mar13
apr13
may13
jun13
jul13
aug13
sep13
oct13
nov13
dec13
State
10.4
10.45
10.37
10.28
10.15
10.03
10.04
9.95
9.95
9.94
9.86
9.79
LAN
10.57
10.7
10.6
10.5
10.31
10.26
10.1
9.92
9.95
9.99
9.84
9.79
Learning Network Composite Score Data
Falls
Pain
3.6
11
3.4
10.5
3.2
10
3
jan13 feb13 mar13 apr13 may13 jun13 jul13 aug13 sep13 oct13 nov13 dec13
State 3.24 3.16 3.22 3.16
LAN
3.53 3.38
3.3
3.2
3.22 3.23 3.22 3.19 3.22 3.33 3.33
3.19 3.25 3.31 3.33 3.27 3.17 3.11 3.32 3.42
9.5
State 10.19 10.17 10.2 10.38 10.21 10.31 10.35 10.43 10.49 10.59 10.26 10.14
LAN
jan13 feb13 mar13 apr13 may13 jun13 jul13 aug13 sep13 oct13 nov13 dec13
9.52
9.95
9.84 10.78 10.47 10.93 10.37 10.37 10.42 10.59 10.01 9.93
Incontinence
Urinary Tract Infection (UTI)
7.8
7.6
7.4
7.2
7
6.8
6.6
6.4
jan13 feb13 mar13 apr13 may13 jun13 jul13 aug13 sep13 oct13 nov13 dec13
57
56
55
54
53
52
51
50
jan13 feb13 mar13 apr13 may13 jun13 jul13 aug13 sep13 oct13 nov13 dec13
State 7.54 7.52 7.37 7.52 7.37 7.17 7.04 7.03 7.19 7.08 6.75 6.59
State 52.24 52.54 52.43 52.73 53.04 52.8 52.94 52.95 53.08 52.8 53.19 52.49
LAN
LAN 54.39 54.78 55.37 55.47 56.25 56.01 55.87 55.52 55.55 54.62 54.75 53.89
7.25 7.26
6.9
7.2
6.83 6.69 6.59 6.89 7.03 7.25 6.81 6.61
Learning Network Composite Score
Physical Restraint
Catheter
1
4.6
4.4
0.8
4.2
4
0.6
3.8
3.6
0.4
jan13 feb13 mar13 apr13 may13 jun13 jul13 aug13 sep13 oct13 nov13 dec13
State 4.07 4.05 3.97 3.94 3.92
LAN
3.8
3.78 3.78 3.88 3.89 3.74 3.78
4.31 4.49 4.48 4.26 4.05 4.08 4.05 4.03 4.12
4.2
3.96 3.99
jan13 feb13 mar13 apr13 may13 jun13 jul13 aug13 sep13 oct13 nov13 dec13
State 0.85
0.83
0.84
0.8
0.81
0.8
0.78
0.75
0.74
0.77
0.74
0.72
LAN
0.66
0.68
0.65
0.66
0.63
0.59
0.54
0.52
0.53
0.5
0.48
0.77
Learning Network Composite Score
Depressive Symptoms
5
4.5
4
3.5
3
jan13 feb13 mar13 apr13 may13 jun13 jul13 aug13 sep13 oct13 nov13 dec13
State 4.25 4.18 4.07 3.93 3.82 3.71 3.74 3.59 3.57 3.42 3.39 3.53
LAN
4.78 4.82 4.42 4.22 3.91 3.64
3.5
3.2
3.43
3.3
3.36 3.65
Pressure Ulcer
9
8.5
8
7.5
7
6.5
jan13 feb13 mar13 apr13 may13 jun13 jul13 aug13 sep13 oct13 nov13 dec13
State 7.19
7.43
7.63
7.74
7.34
7.06
7.03
7.02
7
6.89
6.96
7.14
LAN
7.86
8.45
8.64
8
7.71
7.51
7.56
7.58
7.44
7.4
7.55
7.77
Learning Network Composite Score
Antipsychotic Medications
23
22
21
20
19
18
jan13 feb13 mar13 apr13 may13 jun13 jul13 aug13 sep13 oct13 nov13 dec13
State 22.34 22.42 22.38 22.08 21.98 21.73
LAN 21.53
21.7
21.7
21.46 21.15 20.92 20.49 20.27
21.41 20.83 20.59 20.47 20.25 20.19 19.82 19.55 18.99 18.91
State: RIR = 9.24
Learning Network: RIR = 12. 17
Facility Composite Score Data
Questions and Answers
Updated Individual Data Presentation
Falls
6
5
4
3
2
1
0
jan13 feb13 mar13 apr13 may13 jun13 jul13 aug13 sep13 oct13 nov13 dec13
495123 5.08 5.08 4.24 3.51 3.45 3.45 2.63 2.75 3.7 3.7 4.67 3.85
LAN
3.53 3.38 3.3 3.19 3.25 3.31 3.33 3.27 3.17 3.11 3.32 3.42
State
3.24 3.16 3.22 3.16 3.2 3.22 3.23 3.22 3.19 3.22 3.33 3.33
NNHQCC 3.46 3.46 3.47 3.46 3.43 3.43 3.43 3.42 3.41 3.41 3.44
Share From the Chair
How will you use this data to support your
quality improvement efforts?
How to Use the Data
• Identify improvement opportunities
• Prioritize quality improvement initiatives
• Create and set SMART quality improvement goals
– SMART: Specific, Measureable, Achievable, Relevant, Time
Limit
•
•
•
•
Measurement tool
Root Cause Analysis
Benchmarking
Sustainability
– Identify loss
• Storytelling
– Staff, residents, and families
– Other Stakeholders: Referral Sources,
Surveyors, Ombudsman, etc.
Next Steps
• VHQC:
– Facility will receive data as updated (approximately every 30
days)
– Provide Corporate data
• Facilities:
– Review data with QAPI team and during QA&A Committee
Meetings.
– Analyze data to support quality improvement efforts
– Submit monthly data by the 15th of the month.
– Continue to participate in upcoming NNHQC & Virginia
learning network events.
– Read Taking Root Newsletter
Quality Improvement Resources
• QAPI:
– VHQC
www.vhqc.org (QIO/Resources/Nursing Home Learning Network)
– CMS
http://www.cms.gov/Medicare/Provider-Enrollment- andCertification/QAPI/NHQAPI.html
• Quality Improvement Training Videos:
– The Domestic Lean Goddess – Getting the Kids to School on Time –
PDSA: http://www.youtube.com/watch?v=jsp-19o_5vU
– The Domestic Lean Goddess – Clothing Processing Center – Eliminating
the 7 Wastes: http://www.youtube.com/watch?v=JkXUqxO0FEA
– The Domestic Lean Goddess – Meal Preparation – The 5 S’s of Quality
Improvement: http://www.youtube.com/watch?v=t8Sab61Ok80
• VHQC – Online Community
– http://community.vhqc.org/
Questions and Answers
Contact Information
Sheila McLean, Area Manager
[email protected]
(804) 289-5320
Connect with VHQC
www.twitter.com/VirginiaQIO
www.facebook.com/VHQC1
This material was prepared by VHQC, the Medicare Quality Improvement Organization for Virginia, 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.
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