New Measures Aim to Assess Nursing Home Quality and Safety

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By Jennifer Larson, contributor

March 18, 2011 - A steering committee on nursing homes formed by the National Quality Forum (NQF) has released a new set of 21 measures for assessing the care provided in nursing homes.

Christine Mueller, Ph.D., RN, associate professor of nursing at the University of Minnesota, and co-chair of the committee, called the measures “the best thinking at this time of measures that we think would improve quality in nursing homes.”

“I think we’re getting the best and most effective measures out there,” said David Gifford, M.D., a geriatrician and the other co-chair of the NQF steering committee.

The measures have already been endorsed by the NQF, a voluntary consensus standards-setting organization, but anyone who wishes to ask for reconsideration of any of the measures has until April 1 to submit a written notification. The full set of new measures, which include some measures for long-term residents and some for short-stay patients, is listed on the  NQF website. The NQF is retiring an older set of 17 measures.

Patti Garibaldi, RN, said the measures appear to be “fairly reasonable” and an improvement over the measures that they are replacing.

“I think the public does need to have tools to make choices for the placement of their loved ones and to measure outcomes while they’re in a facility,” said Garibaldi, the director of clinical consulting for Consonus Health in California.

But she added that she’s still waiting to see how some of the measures will be adjusted for risk.

Risk adjustment

Appropriate risk adjustment is very important to nursing home directors who worry that quality measures might not give the whole story.

“I think everybody would like to measure quality in a way that is useful,” said Nancy Beecham, RN, president of the California chapter of the National Association Directors of Nursing Administrators in Long-Term Care (NADONA).

But Beecham, who is the director of a skilled nursing facility with more than 300 beds, hopes that people will realize that quality measures have limitations when it comes to conveying a clear picture of certain nursing facilities.

“You have to take into account the high acuity of the patients we’re taking,” she explained.

For example, Beecham’s facility has a large number of patients with Huntington’s Disease. Many of them fall because of the nature of their illness and because they are not restrained. So Beecham would be concerned about a new quality measure that looks at the percentage of patients who experience one or more falls (with a major injury). She hopes that such measures are very clearly defined to take high risk patients into account.

Relevance to CMS requirements

Facilities won’t be required to adopt the 21 measures. But the Centers for Medicare and Medicaid Services (CMS) may choose to adopt some or all of them because they are relevant to assessing the quality of care experienced by residents of nursing facilities. In fact, the measures were developed as CMS made the transition from one set of standardized assessments to an updated set.

Facilities that are certified by CMS are mandated to use a standardized assessment tool known as the Minimum Data Set, or MDS. They must submit the required information on all their residents to their states. Then the information is entered into a federal CMS database.

The information collected through the MDS is used in the CMS’ Nursing Home Compare tool at Medicare.gov, which people can use when researching nursing homes for themselves or their loved ones.

In 2010, CMS released a timeline for the implementation of an updated set of measurements, the Minimum Data Set 3.0, for nursing homes (and non-critical access hospital swing beds). The MDS 3.0 was developed partially in response to criticisms that the previous set, MDS 2.0, didn’t take into account assessments from nursing home residents themselves.  

The new NQF-endorsed measures also include measures that give assessments from both long-term and short-term patients of their experience in a nursing facility.

The nursing home industry already uses most of the measures—and more—in their own internal quality programs, Gifford noted. But some entities may have really good measures that are proprietary, so they aren’t sharing them. The NQF measures will end up in the public domain.

He hopes that certain issues that, for various reasons, aren’t addressed in the new set of measures will be addressed in future measure sets, though. For example, he’d like to see measures that address dementia because it is a major issue for nursing homes.

And Mueller said that she hopes nurse staffing will be addressed in future measure sets, too. 

“Because the science changes and the industry changes, there will always be better measures that will be recommended and endorsed,” she said.

Going beyond the measures

Garibaldi and Beecham both believe that percentages that are assessed by quality measures are useful,  but they are not the only thing that patients and their families should consider.

Medicare.gov website recommends that people visit nursing homes in person before making a decision. That’s a recommendation echoed by Beecham.

“Go into the building and see what’s going on,” she said.

And Garibaldi hopes that nursing home administrators will educate their staff about new quality measures so they can, in turn, have confidence that they are meeting the standards—and that they are able to explain how they are providing quality care to prospective patients and their families.

“We are taking care of people’s lives and we never forget how critically important that is,” she said.

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