Content contained in this newsletter may have been previously published in prior issues of the QCC newsletter.
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The Florida Nursing Home
Quality Care Connection
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Have you Reviewed Your Nursing Home's Current 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 performance. The CMS goal is for nursing homes to achieve a Composite Score of 6 percent or less. 

For more information, please read the NNHQCC Quality Measure Composite Score handout at  
The most current (July 2016--December 2016) Quality Measure Composite Score report was disseminated to Florida NNHQCC members during face-to-face Learning and Action Network (LAN) Workshops held in Miami, East Orlando, Tallahassee and Tampa on April 2017 - June 2017. If you did not attend one of these workshops and would like to request a copy of your report by mail, please contact HSAG's nursing home team at
Given the Composite Score data is always six months old, the best way to access more recent Quality Measure data is at your fingertips through the MDS 3.0 CASPER Report.
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 Minimum Data Set (MDS) 3.0 Quality Measures User's Manual (v11.0 04-01-2017).
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 goal to lower the use of indwelling catheter is clearly communicated and involves all staff members, residents, and families.
For more information, review HSAG's handout, MDS Coding Guidelines for Indwelling Catheters.

Next month: An Overview of the National Nursing Home Quality Improvement 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. Prioritization Worksheets for PIPs contained in the Quality Assurance & Performance Improvement: An Electronic Resource Library electronic workbook on the HSAG website at
Next month: Plan, Conduct, and Document PIPs
Clostridium difficile Infection (CDI) Prevention Cohort Members
Announcements and Information
  • CDI data for June is due by July 10, 2017.
  • Login to NHSN using your SAMS grid card credentials to submit your CDI LabID events (if applicable) and summary data (total resident days for the month, resident admissions, and residents admitted on CDI treatment)
  • Do not forget to check "Report No Events" under the C. difficile row if there were no positive labs collected within your facility for the month.
  • Resolve Alerts: Review the "Alerts tab and complete missing and/or incomplete data.

HSAG Resource Spotlight
QAPI Resource Library
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.

This session is one of a series of six sessions for nursing homes to support implementation of principles and practices of antibiotic stewardship and prevention and management of C. difficile infections. Learn more.
  Have You Updated Your QAPI Self-Assessment?

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