Quality Measures

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October 19, 2020

MDS 3.0 QM User’s Manual Version 14.0 Now Available

The Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual V14.0 has been posted. The MDS 3.0 QM User’s Manual V14.0 contains detailed specifications for the MDS 3.0 quality measures and includes a Notable Changes section that summarizes the major changes from MDS 3.0 QM User’s Manual V13.0. The MDS 3.0 QM User’s Manual V14.0 can be found in the Downloads section of this webpage, grouped with other Skilled Nursing Facility (SNF) and Nursing Home user’s manuals in a zip file titled Users-Manuals-Updated-10-19-2020. The zip file titled User Manuals - Updated 01-21-2020 (ZIP) containing the MDS 3.0 QM User’s Manual V13.0 has been moved to the Quality Measures Archive webpage.

The zip file titled Users-Manuals-Updated-10-19-2020 includes five files:

  1. MDS 3.0 QM User’s Manual V14.0 (MDS-3_0-QM-USERS-MANUAL-v14_0.pdf) contains detailed specifications for the MDS 3.0 quality measures, as well as the Quality Measure Reporting Module Table that documents the Centers for Medicare & Medicaid Services (CMS) quality measures calculated using MDS 3.0 data and reported in a CMS reporting module.
  2. Nursing Home Compare Claims-based Quality Measure Technical Specifications (Nursing Home Compare Claims-based Measures Tech Specs.pdf) contains detailed technical specifications for all nursing home quality measures.
  3. Nursing Home Compare Quality Measures Technical Specifications Appendix (APPENDIX - Claims-based measures Technical Specifications.pdf) contains tables and appendices related to the Nursing Home Compare Claims-based Quality Measures.
  4. Skilled Nursing Facility Quality Reporting Program (SNF QRP) Measure Calculations and Reporting User’s Manual V3.0 (SNF Measure Calculations and Reporting User's Manual V3.0_FINAL_508C_081419.pdf) contains detailed specifications for all SNF QRP Quality Measures.
  5. SNF QRP Measure Calculations and Reporting User’s Manual Version 3.0.1 (SNF-QRP-QM-Users-Manual-V3_0_1-Addendum-Change-Table.pdf) contains appendices for the SNF QRP Measure Calculations and Reporting Manual V3.0, including a risk adjustment appendix and Hierarchical Condition Category (HCC) crosswalks.

Nursing home quality measures have four intended purposes:

  • To give you information about the quality of care at nursing homes in order to help you choose a nursing home for yourself or others;
  • To give you information about the care at nursing homes where you or family members already live;
  • To give you information to facilitate your discussions with the nursing home staff regarding the quality of care; and
  • To give data to the nursing home to help them in their quality improvement efforts.

The nursing home quality measures come from resident assessment data that nursing homes routinely collect on the residents at specified intervals during their stay. These measures assess the resident's physical and clinical conditions and abilities, as well as preferences and life care wishes. These assessment data have been converted to develop quality measures that give consumers another source of information that shows how well nursing homes are caring for their resident's physical and clinical needs.

The current quality measures have been chosen because they can be measured and don't require nursing homes to prepare additional reports. They are valid and reliable. However, they are not benchmarks, thresholds, guidelines, or standards of care. The quality measures are based on care provided to the population of residents in a facility, not to any individual resident, and are not appropriate for use in a litigation action.

These quality measures were selected because they are important. They show ways in which nursing homes are different from one another. There are things that nursing homes can do to improve their quality measure percentages. The quality measures have been validated and are based on the best research currently available. As this research continues, scientists will keep improving the quality measures on this website.

The quality measure short stay and long stay definitions are:

  • The short stay resident quality measures show the average quality of resident care in a nursing home for those who stayed in a nursing home for 100 days or less or are covered under the Medicare Part A Skilled Nursing Facility (SNF) benefit. Short-stay residents often are those recovering from surgery or being discharged from a hospital stay. Many short-stay residents get care in a nursing home until they’re able to go back home or to the community.
  • The long stay resident quality measures show the average quality of care for certain care areas in a nursing home for those who stayed in a nursing home for 101 days or more. Residents in a nursing home for a long-stay are usually not healthy enough to leave a nursing home and can’t live at home or in a community setting. These residents may be older and have more serious health issues.

The current nursing home quality measures are:

Short Stay Quality Measures

  • Percent of Short-Stay Residents Who Were Re-Hospitalized after a Nursing Home Admission.
  • Percent of Short-Stay Residents Who Have Had an Outpatient Emergency Department Visit.
  • Percent of Residents Who Newly Received an Antipsychotic Medication.
  • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
  • Percent of Residents Who Made Improvements in Function
  • Percent of Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
  • Percent of Residents Who Received the Seasonal Influenza Vaccine*
  • Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine*
  • Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal* Influenza Vaccine.
  • Percent of Residents Who Were Assessed and Appropriately Given the Pneumococcal Vaccine
  • Percent of Residents Who Received the Pneumococcal Vaccine*
  • Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine*
  • Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Pneumococcal Vaccine*
  • * These measures are not publicly reported but available for provider preview.

Long Stay Quality Measures

  • Number of Hospitalizations per 1,000 Long-Stay Resident Days.
  • Number of Outpatient Emergency Department Visits per 1,000 Long-Stay Resident Days.
  • Percent of Residents Who Received an Antipsychotic Medication.
  • Percent of Residents Experiencing One or More Falls with Major Injury.
  • Percent of High-Risk Residents with Pressure Ulcers.
  • Percent of Residents with a Urinary Tract Infection.
  • Percent of Residents who Have or Had a Catheter Inserted and Left in Their Bladder.
  • Percent of Residents Whose Ability to Move Independently Worsened.
  • Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased.
  • Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
  • Percent of Residents Who Received the Seasonal Influenza Vaccine*
  • Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine*
  • Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine*
  • Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine
  • Percent of Residents Who Received the Pneumococcal Vaccine*
  • Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine*
  • Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Pneumococcal Vaccine*
  • Percent of Residents Who Were Physically Restrained.
  • Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder.
  • Percent of Residents Who Lose Too Much Weight.
  • Percent of Residents Who Have Symptoms of Depression.
  • Percent of Residents Who Used Antianxiety or Hypnotic Medication.

* These measures are not publicly reported but available for provider preview.

Quality measure specifications are available in the QM Users’ Manual download file, which can be found under the download section below. A sub-group of quality measures are incorporated into the Five-Star Quality Rating System and used to determine scoring for the quality measures domain on Nursing Home Compare.

Page Last Modified:
11/19/2021 08:47 AM