Monthly Quality Indicator Comparison Reports Policy

3319 - Monthly Quality Indicator Comparison Reports Policy (Rev. 1, 05-21-04) 3319A - Purpose (Rev. 1, 05-21-04) The Monthly Quality Indicator Comparison Report was created by CMS in order to give state personnel and facilities a report that can be selectively released to certain requestors without violating the confidentiality of resident information. The Facility Quality Indicator Profile Reports, which provide data on the MDS-based quality indicators at a facility level have been available for some time. Because of issues of resident privacy, it has not been permissible to release these reports to requestors such as consumers. The Monthly Quality Indicator Comparison Report contains facility-level information while conforming to privacy rules; thus, States and facilities may release these reports. 3319B - Contents (Rev. 1, 05-21-04) The Monthly Quality Indicator Comparison Report is based on the same data used to produce the Facility Quality Indicator Profile Report, but the data are presented differently. (A sample of the report is attached to Survey and Certification Policy Letter 01-17.) The Monthly Quality Indicator Comparison Report contains both state percent and national percent comparison columns. This allows the reviewer to compare the performance on each quality indicator measure to that of the state and of the nation. The state percent column contains the “percent triggered” for the quality indicator averaged over all facilities within the state. This is an unweighted average, meaning that each facility has an equal impact on the average, regardless of number of residents. The national percent is also an unweighted average. It represents the “percent triggered” for the quality indicator averaged over all the facilities in the nation. 3319C - Differences From Facility Quality Indicator Profile Report (Rev. 1, 05-21-04) Because of concerns with protection of the privacy of residents, some of the data presented on the Facility Quality Indicator Profile Report are not included on the Monthly Quality Indicator Comparison Report. The numerator and denominator used to calculate the percents are not presented on the Monthly Quality Indicator Comparison Report. Additionally, totals are not displayed in instances when the number of residents in a facility is 10 or fewer. Also, if the percent triggered is 90 percent or greater for any given quality indicator, the exact percent triggered will not be displayed. Instead, a notation indicating that the percent triggered is “greater than or equal to 90 percent” will be displayed. 3319D - Delivery of Report (Rev. 1, 05-21-04) At the end of every month, the Monthly Quality Indicator Comparison Report is generated for each facility within a state, and is placed in that facility’s directory. The report does not allow an option for user-defined dates. Due to a built-in lag in the data system, the data that appear on the report generated in a given month are based on quality indicators from four months prior. The name of the report text file in the directory reflects this. The file name is MSRmmyyyy.txt, where mmyyyy is the month and year of the data from which the report was created. This date also appears at the top of the report itself. 3319E - Release of Report (Rev. 1, 05-21-04) The Monthly Quality Indicator Comparison Reports were designed for use by: 1. Family members of a facility resident; 2. Potential facility residents or their family members; and 3. The State ombudsman. Release of the reports for a large number of facilities or to individuals other than those named above is at the State’s discretion. Although CMS has suppressed certain data in order to protect individual privacy, the state and the facilities must be cautious in evaluating requests for these reports and in releasing them: • The reports were designed to enable individuals with a personal or professional interest in a facility, or a few facilities to have access to quality indicator information at a facility level. A State ombudsman, discharge planner, or other appropriate person could help the consumer understand and utilize the information in a small number of reports. • Since release of these reports was not designed for large batches, the data system does not include a direct method to print reports for a large number of facilities at once. • Explanatory language appropriate for consumers is not included with the reports; therefore the reports are not designed to be published or to be posted on the Internet. • State or facility staff should remind recipients of the reports that the information contained in the report is not a measure of a facility’s quality, but is rather an indicator of the potential for quality problems. Recipients should not use these reports alone to draw conclusions about a facility’s quality. They should also visit the facilities that they are evaluating. • Each recipient of a Monthly Quality Indicator Comparison Report should also receive a copy of the sheet “The Monthly Quality Indicator Comparison Report: Guidelines” (see F below). The sheet will aid recipients in the appropriate use of the report. 3319F - Monthly Quality Indicator Comparison Report Guidelines (Rev. 1, 05-21-04) The Monthly Quality Indicator Comparison Report was created by the CMS to give individuals with either a personal or a professional interest in a specific facility access to facility-level data on quality indicators without violating the confidentiality of the nursing home residents. The report allows comparisons between a specific nursing home and the state, as well as the nation about the proportion of residents with a particular condition. • The data in these reports are only a starting point in reaching a decision about the quality of a nursing facility. The data should be viewed as measures of the potential for quality problems. There may be a legitimate reason why a facility has higher than average percentages on a particular indicator. • In making decisions about quality of care, it is important to actually visit the nursing home being considered. Information in this report can help decide what type of questions an individual may want to ask on a visit to the nursing home. • Additional information about individual facilities can be found in the Nursing Home Compare section of the CMS Web site http://www.medicare.gov/. This includes the State inspection results, found in the “About the Nursing Home Inspections Results” section of this web site.