QIO - HSAG logos


The Florida Nursing Home Quality Care Connection
Nursing Home Event Icons
Do you know your nursing
home's Quality Measure
Composite Score?
The Quality Measure Composite Score, developed
by the Centers for Medicare & Medicaid Services (CMS), comprises 13 long-stay measures and is an excellent "barometer" of your facility's implementation of Quality Assurance & Performance Improvement (QAPI). Your Florida National Nursing Home Quality Care Collaborative (NNHQCC) team provides this
data to you. 
Ideas for Indwelling Catheters
Indwelling catheters can be uncomfortable and inhibit mobility. They can also lead to serious complications and infections. The indwelling catheter quality measure (QM) reports the percentage of residents who had an indwelling catheter at any time during the 7-day look-back period. The denominator of this QM includes all long-stay residents with a selected target assessment, except those with the following exclusions:
  1. Target assessment is an admission assessment or a Prospective Payment System (PPS), 5-day, or readmissions assessment.
  2. Assessment indicates indwelling catheter status is missing.
  3. Assessment shows resident has a diagnosis of neurogenic bladder and/or obstruction and these diagnoses are coded on the Minimum Data Set (MDS).
Learn more about the calculation of this QM on page 34 of the MDS 3.0 Quality Measures User's Manual (v9.0 08-15-2015).
Performance Improvement Project (PIP) teams should assess whether residents with catheters really require them based on specific diagnoses and conditions. PIP teams should work to improve their indwelling catheter QM and consider some of these questions to help their quality improvement efforts:
  • Was the MDS coded per Resident Assessment Instrument requirements?
  • Did the resident have a diagnosis of neurogenic bladder and/or obstruction and was this coded on the MDS?
  • Is it possible to complete post-void residuals or straight catheterization to eliminate the use of the indwelling catheter?
Additionally, PIP teams must ensure their PIP goal to lower the use of indwelling catheters is clearly communicated and involves all staff members, residents, and families.
Next issue: An Overview of the Advancing Excellence in America's Nursing Homes Campaign
QAPI Corner
STEP 9: Prioritize Quality Opportunities and Charter PIPs
With this step, Quality Assurance & Performance Improvement (QAPI) starts to focus on the "performance-improvement" side of QAPI. Prioritizing the opportunities for improvement you identified in Step 7 (Identify Your Gaps & Opportunities) is a key step in the process of translating data into action. You and your team need to decide which opportunities:
  • Need to be addressed now.
  • Carry the most importance to your residents, facility, and staff members.
  • Are "low-hanging fruit" and can be quickly and simply rectified.
Once your opportunities are prioritized, it is time to "charter" your PIP team. To charter means to entrust the team with a mission that is truly important to everyone in your facility. This team should :
  • Include people who bring different but equally important perspectives to the table. 
  • Include anyone from department heads to nurse aides to residents. 
  • Involve individuals who have expertise, knowledge, and/or background that make them important members of the PIP team.
For more information on this topic, read page 16 of QAPI at a Glance.

Next issue: Plan, Conduct, and Document PIPs
HSAG Resource Spotlight
Access all of the CMS tools for QAPI from one easy-to-use electronic resource library. Learn more.
This QAPI Plan Template can help guide nursing home staff members as they develop specific quality improvement plans for their organizations. Learn more.
This guide helps walk your team through the action steps of developing your organization's QAPI plan. Learn more.
Have you completed your QAPI Self-Assessment? 
Register Now!
The third round of Florida NNHQCC learning sessions are coming soon. Make plans to attend!
Thursday, April 7
9:00 to 11:30 a.m. (ET)
Miami Jewish
Health Systems
Thursday, April 14
9:00 to 11:30 a.m. (ET)
Westminster Woods on Julington Creek
Thursday, April 21
9:00 to 11:30 a.m. (ET)
The Rehabilitation Center of the Palm Beaches
Thursday, April 28
9:00 to 11:30 a.m. (ET)
Tallahassee Memorial Hospital Extended Care
Tuesday, May 3
9:00 to 11:30 a.m. (ET)
HSAG Office
Thursday, May 12
9:00 to 11:30 a.m. (ET)
Azalea Trace - WillowBrooke Court
Tuesday, May 17
9:00 to 11:30 a.m. (ET)
Good Samaritan Society - Florida Lutheran
Register for this upcoming webinar!
Insights for Improving Your Pain Quality Measures
March 29
2:00 to 3:15 p.m. (ET)

Subscribe to our YouTube channel

Quick Links