mds 3.0 quality measure reports

11
MDS 3.0 QUALITY MEASURE (QM)
REPORTS
GENERAL INFORMATION ........................................................................................2
INTRODUCTION ......................................................................................................2
SUPPORTING QM CONCEPTS .................................................................................2
ACCESSING THE MDS 3.0 QM REPORTS ................................................................4
MDS 3.0 FACILITY CHARACTERISTICS REPORT ..................................................5
MDS 3.0 FACILITY LEVEL QUALITY MEASURE REPORT ......................................9
MDS 3.0 RESIDENT LEVEL QUALITY MEASURE REPORT..................................14
MDS 3.0 MONTHLY COMPARISON REPORT .......................................................17
CASPER MDS 3.0 QM REPORTS VS. NURSING HOME COMPARE ....................20
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MDS 3.0 QM 11-1
GENERAL INFORMATION
Introduction
This section of the CASPER Reporting User’s Guide explains the information
that is presented in the MDS 3.0 Quality Measure (QM) reports in addition to
how to access these reports. It does not provide a full explanation of either
the ways in which the resident samples are selected to produce the reports or
the calculation logic that is used for each of the QMs. For complete details of
record selection and measure definitions refer to the MDS 3.0 Quality
Measures User’s Manual that is posted on CMS’s web site.
NOTE: We strongly urge users of the QM reports to consult the MDS 3.0
Quality Measures User’s Manual in order to understand the reports and to
use them properly.
Included at the end of this section of the CASPER Reporting User’s Guide is
a description of the differences between the CASPER MDS 3.0 QM reports
and the information available on the Nursing Home Compare web site.
Supporting QM Concepts
An assessment’s target date is identified based on the value of A0310F,
Entry/Discharge Reporting. The following is a list of target dates:
•
Discharge Date (A2000) for A0310F = 10, 11 or 12
•
Entry Date (A1600) for A0310F = 01
•
Assessment Reference Date (A2300) for A0310F = 99
Resident ID is an internal ID that the MDS 3.0 Submission system assigns to
the resident. It is not an ID assigned to the resident by the Long Term Care
facility. This ID number is not the same as the Resident ID field of the MDS
data set.
NOTE: Only federally required (A0410 = 3) assessments and residents for
whom federally required assessments were submitted are included in the
MDS 3.0 QM reports.
The MDS 3.0 Quality Measures are as follows (“S” indicates a short-stay
measure and “L” indicates long-stay measure; abbreviated measure names
appear on the reports):
•
Self-Reported Moderate to Severe Pain (S)
•
Self-Reported Moderate to Severe Pain (L)*
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•
High-Risk Residents with Pressure Ulcers (L)
•
New/Worsened Pressure Ulcers (S)*
•
Physical Restraints (L)
•
Falls (L)
•
Falls with Major Injury (L)
•
Residents Who Newly Received an Antipsychotic Medication (S)
•
Residents Who Received an Antipsychotic Medication (L)
•
Antianxiety/Hypnotic Medication Use (L)
•
Behavior Symptoms Affecting Others (L)
•
Depressive Symptoms (L)
•
Urinary Tract Infection (L)
•
Catheter Inserted and Left in Bladder (L)*
•
Low-Risk Residents Who Lose Bowel/Bladder Control (L)
•
Excessive Weight Loss (L)
•
Need for Help with ADLs Has Increased (L)
* Risk-adjusted Quality Measure using resident-level covariates for public
reporting.
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MDS 3.0 QM 11-3
Accessing the MDS 3.0 QM Reports
MDS 3.0 Quality Measure (QM) Reports are requested on the CASPER
Reports page (Figure 11-1).
Figure 11-1.
CASPER Reports Page – MDS 3.0 QM Reports Category
1. Select the MDS 3.0 QM Reports link from the Report Categories frame on
the left. A list of the MDS 3.0 Quality Measure reports you may request
displays in the right-hand frame.
NOTE: Only those report categories to which you have access are listed in
the Report Categories frame.
2. Select the desired underlined report name link from the right-hand frame.
One or more CASPER Reports Submit pages are presented providing
criteria options with which you specify the information to include in your
report. These options may differ for each report.
3. Choose the desired criteria and select the Submit or Next button.
NOTE: MDS 3.0 reports access detailed information and may require a
significant amount of time to process. Once you submit your report
request(s), you may consider exiting the CASPER Reporting application, and
viewing the completed report(s) at a later time.
4. Refer to Section 2, Functionality, of the CASPER Reporting User’s Guide
for assistance in viewing, printing, saving, and exporting the reports you
request.
NOTE: MDS 3.0 reports are automatically purged after 60 days.
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MDS 3.0 FACILITY CHARACTERISTICS REPORT
The MDS 3.0 Facility Characteristics Report identifies potential areas for
further emphasis or review as part of a survey or a facility’s quality assurance
and improvement processes. It provides facility demographic information and
includes comparison state and national percentages for a specified
timeframe. By comparing the facility percentages with the state and national
average percentages, you can determine whether the facility’s demographic
characteristics differ from the norm. The MDS 3.0 Facility Characteristics
report is only available for nursing homes (A0200 = 1) submitting Federal
(A0410 = 3) assessments.
Facility characteristics may indicate a need to concentrate a review on certain
resident groups. Examples include:
•
A very old population
•
An unusually high percentage of male residents
•
A higher than average percentage of residents with psychiatric,
intellectually disabled, or developmentally disabled diagnoses
•
A higher than average percentage of residents receiving hospice care
•
A higher than average percentage of admission assessments
The criteria page (Figure 11-2) provides Begin Date, End Date, and
Comparison Group options. It also indicates the date on which the current
data were calculated and available for reporting.
Figure 11-2. CASPER Reports Submit Page – MDS 3.0 Facility Characteristics
Report
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The Begin and End dates define the date range of data to report. Beginning
and ending dates for the previous full six-month period are pre-filled into
these fields. You may enter different dates in mm/dd/yyyy format. The Begin
date must be 10/01/2010 or later, but must not be later than the date the
current data were calculated. The End date must be later than the Begin
date. Future dates are not valid. Error messages appear if the date criteria
are invalid.
State and national comparison data are delayed by two months in order to
allow for the time it takes to finalize and publicize this data. The most recent
six-month period available for reporting state and national comparison data
are three months prior to the current month. The default value of the
Comparison Group field is the most recent six-month period. You may select
earlier periods from the drop-down list.
The MDS 3.0 Facility Characteristics Report (Figure 11-3) is divided into two
sections: the header and the body. The information contained in the header
is as follows:
•
Facility ID. The facility’s ID used for submission of MDS 3.0 records.
•
CCN. The facility’s CMS Certification Number.
•
Facility Name. The name of the facility.
•
City/State. The location of the facility.
•
Data was calculated on. The QM statistics are automatically
recalculated weekly in order to account for newly submitted data. The
date in this field shows the last date this system calculation occurred.
•
Report period. The dates in this field reflect the reporting period that was
selected by the user when the report was requested.
•
Comparison group. State and national statistics are automatically
calculated for various time periods and these pre-calculated statistics are
used to produce comparison group statistics in the body of the report. The
dates in this field indicate the comparison group time period that was used
for the report.
•
Run date. This is the date that the report was run.
•
Report version number. As the reporting system software is updated,
this version number will change. This field shows the version that was
used to produce the report.
The body of the MDS 3.0 Facility Characteristics Report details the Facility
Numerator, Facility Denominator, Facility Observed Percentage, Comparison
Group State Average, and Comparison Group National Average for each of
the following resident characteristics for the selected facility and reporting
period:
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•
Gender
o Male
o Female
•
Age
o <25 years old
o 25-54 years old
o 55-64 years old
o 65-74 years old
o 75-84 years old
o 85+ years old
•
Diagnostic Characteristics
o Psychiatric diagnosis
o Intellectual or Developmental Disability
o Hospice
•
Prognosis
o Life expectancy of less than 6 months
•
Discharge Plan
o Not already occurring
o Already occurring
•
Referral
o Not needed
o Is or may be needed but not yet made
o Has been made
•
Type of Entry
o Admission
o Reentry
•
Entered Facility From
o Community
o Another nursing home
o Acute Hospital
o Psychiatric Hospital
o Inpatient Rehabilitation Facility
o ID/DD facility
o Hospice
o Long Term Care Hospital
o Other
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Figure 11-3. MDS 3.0 Facility Characteristics Report
The Numerator indicates the number of residents with the identified
characteristic and the Denominator indicates the number of residents in the
facility.
Simple average percentages are provided for each resident characteristic
among all facilities in the state and nation for the selected Comparison Group
period.
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MDS 3.0 FACILITY LEVEL QUALITY MEASURE REPORT
For each QM, the MDS 3.0 Facility Level Quality Measure Report shows the
facility percentage and how the facility compares with other facilities in their
state and in the nation. This report helps facilities identify possible areas for
further emphasis in facility quality improvement activities or investigation
during the survey process.
The MDS 3.0 Facility Level Quality Measure Report displays QM numerator
and denominator counts for a select period. It includes the facility’s observed
and adjusted triggered percentages as well as state and national average
percentage comparisons and a national ranking for each measure.
The criteria selection page (Figure 11-4) for the MDS 3.0 Facility Level
Quality Measure Report presents Begin Date (mm/dd/yyyy), End Date
(mm/dd/yyyy), and Comparison Group options. The date the most recent
quality measure data were calculated is indicated.
Figure 11-4. CASPER Reports Submit Page - MDS 3.0 Facility Level Quality
Measure Report
Begin Date (mm/dd/yyyy) and End Date (mm/dd/yyyy) dates are pre-filled for
the most recent completed six-month period prior to the month the data were
last calculated. You may enter alternate dates in an mm/dd/yyyy format. An
error message is presented if the date criteria are invalid. Examples include
an incorrect date format, the Begin Date being after the End Date, the Begin
Date being prior to 10/01/2010, the End Date being after the date on which
the data were calculated, and the use of future dates or alpha characters.
NOTE: MDS 3.0 quality measure data are only available for assessments
with target dates 10/01/2010 and later.
Comparison Group date range options include six-month intervals, beginning
10/01/2010. The most recent six-month period available for reporting state
and national comparison data ends three months prior to the current month.
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NOTE: State and National comparison group data are calculated monthly on
the first day of the month. Data calculation is delayed by two months in order
to allow for submission of late and corrected assessments. Comparison data
are not recalculated if assessments with target dates that fall in periods for
which comparison group data were already calculated are received.
The Data was calculated on date displays at the bottom of the criteria
selection page.
NOTE: Quality Measure data are calculated weekly for the assessments
submitted since the previous week’s data calculation.
The MDS 3.0 Facility Level Quality Measure Report (Figure 11-5) is divided
into two sections: the header and the body. The information contained in
these sections is as follows:
Header
•
Facility ID. The facility’s identifier.
•
CCN. The facility’s CMS Certification Number.
•
Facility Name. The name of the facility.
•
City/State. The location of the facility.
•
Data was calculated on. The QM statistics are automatically
recalculated periodically in order to account for newly submitted data. The
date in this field shows the last date this system calculation occurred.
•
Report period. The dates in this field reflect the reporting period that was
selected by the user when the report was requested.
•
Comparison group. State and national statistics are automatically
calculated on a periodic basis for various time periods and these precalculated statistics are used to produce comparison group statistics in the
body of the report. The dates in this field indicate the comparison group
time period that was used for the report.
•
Run date. This is the date that the report was run.
•
Report version number. As the reporting system software is updated,
this version number will change. This field shows the version that was
used to produce the report.
•
Legend. The header contains the following notes that explain the
symbols and abbreviations that are used in the body of the report:
o Dashes represent a value that could not be computed
o S = short stay, L = long stay
o I = incomplete; data not available for all days selected
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o
* is an indicator used to identify that the measure is flagged
Body
•
Measure description. The first column of the report contains a brief
description of the measure.
•
CMS ID. This column contains the unique identification number assigned
by CMS to each measure.
•
Data. The letter “I” displays in this column if the measure was not active
during the entire selected report period.
•
Num. This column shows the number of residents who triggered the QM.
These are the people who "have" the QM. For the purposes of calculating
the facility percentage, it is the numerator.
•
Denom. This column shows the number of people in the facility who
"could have" the QM. For the purposes of calculating facility percentage,
it is the denominator. For some measures, the number of cases in the
denominator equals the current number of short-stay or long-stay
residents in the facility. For other measures, the denominator is smaller
either because of risk group definitions or because of exclusions that were
applied to the denominator.
•
Facility Observed Percent. This column shows the percentage of
residents who could have the QM and actually triggered it, and is
computed by dividing the numerator by the denominator. For example, if
60 people could trigger a measure (Denom column) and 30 people
actually did trigger it (Num column), the Facility Observed Percent column
is 50.0%.
•
Facility Adjusted Percent. This column shows the Adjusted Percent,
which is computed using a mathematical model that takes various resident
characteristics and the national percent for the measure into account and
adjusts the observed percent accordingly. This methodology is applied to
only a subset of measures. Measures that are adjusted have a different
value in the adjusted and observed percent columns. For measures that
are not adjusted, the value in the observed percent column is repeated in
the adjusted percent column.
•
Comparison group state average. This column shows the average
statewide percentage for the QM for comparison with the facility. It
represents the average of the observed percentages (or the adjusted
percentages, for risk-adjusted measures) across all facilities in the state in
which the facility is located.
•
Comparison group national average. This column shows the average
national percentage for the QM for comparison with the facility. It
represents the average of the observed percentages (or the adjusted
percentages, for risk-adjusted measures) across all facilities in the nation.
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•
Comparison group national percentile. The national percentile column
ranks facilities relative to other facilities in the nation on each measure.
The higher the ranking, the more likely the measure should be reviewed
as part of the facility quality improvement process or emphasized on the
survey.
The values in this column represent the percent of facilities in the nation
that are at or below the observed (or adjusted) percentage for the facility.
For example, if the facility is at the 85th percentile for a measure, it means
that 85% of the facilities in the nation have an observed (or adjusted)
percentage that is at or below the facility’s percentage.
Some of the values in this column may be followed by an asterisk. The
asterisk identifies those measures that crossed an investigative threshold
(were “flagged”). QMs at or above the 75th percentile in this column are
designated with an asterisk (*). This identifies those measures where the
facility’s ranking is high enough that it should be investigated or
emphasized on the survey or in any internal quality improvement initiative
and may indicate a possible concern with regard to quality of care. It is an
area to highlight for investigation or emphasis during offsite survey
preparation or to choose for review in the facility quality assurance or
quality improvement processes.
Note that just because a QM was flagged (exceeds a threshold) does not
mean that there is an automatic assumption of a problem. It means that
the information suggests that there is a concern that should be reviewed
to see whether a problem exists and, if so, how it is being addressed.
Note also that just because a facility is not flagged does not mean that
there is not a problem with the quality of care in that area. You must
consider all of the information available, and use your best clinical
judgment. The QM information is only a tool for surveyors and facility staff
to use. It is not the only information on which to base quality assurance
and improvement activities or to make assumptions about care.
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Figure 11-5. MDS 3.0 Facility Level Quality Measure Report*
* Fictitious, sample data are depicted.
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MDS 3.0 RESIDENT LEVEL QUALITY MEASURE REPORT
The MDS 3.0 Resident Level Quality Measure Report identifies the residents
(active and discharged) that were included in the calculations for the facility
and period that were used to produce the MDS 3.0 Facility Level Quality
Measure Report. The report lists the residents by name and indicates the
measures, if any, triggered by each.
The criteria selection page (Figure 11-6) for the MDS 3.0 Resident Level
Quality Measure Report presents Begin Date (mm/dd/yyyy) and End Date
(mm/dd/yyyy) options. The date the most recent quality measure data were
calculated is indicated.
Figure 11-6. CASPER Reports Submit Page - MDS 3.0 Resident Level Quality
Measure Report
Begin Date (mm/dd/yyyy) and End Date (mm/dd/yyyy) dates are pre-filled for
the most recent completed six-month period prior to the month the data were
last calculated. You may enter alternate dates in an mm/dd/yyyy format. An
error message is presented if the date criteria are invalid. Examples include
an incorrect date format, the Begin Date being after the End Date, the Begin
Date being prior to 10/01/2010, the End Date being after the date on which
the data were calculated, and the use of future dates or alpha characters.
NOTE: MDS 3.0 quality measure data are only available for assessments
with target dates 10/01/2010 and later.
The Data was calculated on date displays at the bottom of the criteria
selection page.
NOTE: Quality Measure data are calculated weekly for the assessments
submitted since the previous week’s data calculation.
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The MDS 3.0 Resident Level Quality Measure Report (Figure 11-7) is divided
into two sections: the header and the body. The information contained in
these sections is as follows:
Header
•
Facility ID. The facility’s ID.
•
Facility name. The name of the facility.
•
CCN. The facility’s CMS Certification Number.
•
City/State. The location of the facility.
•
Data was calculated on. The QM statistics are automatically
recalculated periodically in order to account for newly submitted data. The
date in this field shows the last date this system calculation occurred.
•
Report period. The dates in this field reflect the reporting period that was
selected by the user when the report was requested.
•
Run date. This is the date that the report was run.
•
Report version number. As the reporting system software is updated,
this version number will change. This field shows the version that was
used to produce the report.
•
Legend. The header contains a note that explain symbols and
abbreviations that are used in the body of the report.
o S = short stay
o L = long stay
o X = triggered
o B = not triggered or excluded
o C = complete; data available for all days selected
o I = incomplete; data not available for all days selected
Body
•
Data. For each measure, the Data row indicates with an I if the measure
is not active during the entire report period or a C if measure data are
complete for the selected dates.
Residents are listed in two groups: active residents and discharged residents
(residents whose last MDS record during the target period was a discharge).
Residents are listed in alphabetical order within each of these two groups.
For each resident, the following data elements are presented:
•
Resident name. The first column shows the resident’s full name.
•
Resident ID. The unique internal ID that is used by the QIES system to
identify the resident.
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•
•
A0310A/B/F. This column identifies the reasons for assessment for the
resident’s target record. A value of 99/99/01 represents a new resident
who does not have a target assessment as of the end of the reporting
period. The reason for assessment items are:
o
A0310A: Federal OBRA reason for assessment
o
A0310B: PPS assessment
o
A0310F: Entry/discharge reporting
QM columns. Following the identifying information, the report contains
columns for each QM. An X appears in the QM column when the resident
triggers a measure (i.e., is included in the numerator for that measure),
and a b (“blank”) appears for residents who did not trigger or who were
excluded from the measure. The last column in each row displays a count
of the number of measures that were triggered for the resident.
The Resident Level Quality Measure Report can be used in two ways. First, it
can be used to identify the residents that trigger a particular QM (by scanning
a column of interest and looking for the residents with an X). Second, it can
be used to identify residents who trigger multiple QM measures. Such
residents may merit special consideration or more intensive review.
Figure 11-7. MDS 3.0 Resident Level Quality Measure Report*
* Fictitious, sample data are depicted.
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MDS 3.0 MONTHLY COMPARISON REPORT
The MDS 3.0 Quality Measure Monthly Comparison Report presents
observed or adjusted percentages for each QM for the facility, the state, and
the nation. It allows easy comparison of these percentages for each measure
for a specified six-month period.
Since the report is intended for public use, data for measures with small
denominators (less than 30 for long-stay measures and less than 20 for shortstay measures) or high-triggered percentages are suppressed.
Data for this report are calculated on the first day of each month using
accepted assessment records with target dates two months prior to the month
of calculation.
The criteria selection page (Figure 11-8) for the MDS 3.0 Monthly
Comparison Report presents Begin Month (mm/yyyy) and End Month
(mm/yyyy) options.
Figure 11-8. CASPER Reports Submit Page - MDS 3.0 Monthly Comparison
Report
Begin Month (mm/yyyy) and End Month (mm/yyyy) dates are pre-filled for the
previous full six-month period. You may select an alternate End Month from
the drop-down list. Based upon the End Month selection, the system
calculates and displays the Begin Month 6 months prior.
NOTE: MDS 3.0 quality measure data are only available for assessments
with target dates 10/01/2010 and later.
The MDS 3.0 Quality Measure Monthly Comparison Report (Figure 11-9) is
divided into two sections: the header and the body. The information
contained in these sections is as follows:
Header
•
Facility ID. The facility’s ID.
•
CCN. The facility’s CMS Certification Number.
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•
Facility name. The name of the facility.
•
City/State. The location of the facility.
•
Report period. The dates in this field reflect the reporting period that was
selected by the user when the report was requested.
•
Run date. This is the date that the report was run.
•
Report version number. As the reporting system software is updated,
this version number will change. This field shows the version that was
used to produce the report.
•
Legend. The header contains notes that explain symbols and
abbreviations that are used in the body of the report. The sample sizes for
both the long-stay and short-stay measures are noted.
Body
•
CMS ID. This column contains the unique identification number assigned
by CMS to each measure.
•
Data. The letter “I” displays in this column if the measure was not active
during the entire selected report period.
•
Measure description. The first column of the report contains a brief
description of the measure.
•
Facility percent. The Facility Percent is either the adjusted percent, for
measures that are risk adjusted, or observed percents for other measures.
The adjusted percent is computed using a mathematical model that takes
various resident characteristics and the national percent for the measure
into account and adjusts the observed percent accordingly. For measures
that are not adjusted, the value in the facility percent column is simply
computed by dividing the facility’s numerator by the denominator for the
measure. N/A displays in this column when the measure value is
suppressed.
•
State percent. The state percent is the average of the facility
percentages for all facilities in the state. It represents an average of the
adjusted percentages for measures that are risk adjusted or the average
of the observed percentages for measures that are not risk adjusted.
•
National percent. The national percent is the average of the facility
percentages for all facilities in the nation. It represents an average of the
adjusted percentages for measures that are risk adjusted or the average
of the observed percentages for measures that are not risk adjusted.
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Figure 11-9. MDS 3.0 Quality Measure Monthly Comparison Report*
* Fictitious, sample data are depicted.
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CASPER MDS 3.0 QM REPORTS VS. NURSING HOME COMPARE
Even though CASPER MDS 3.0 QM reports and Nursing Home Compare
(NHC) use identical sample selection and measure calculation logic, there
may be differences between the results that are reported by the two systems.
The reasons for these differences are:
•
Measures Included. The CASPER MDS 3.0 QM reports and the reports
on NHC contain many of the same measures. However, NHC contains
some QMs that are not included in the CASPER MDS 3.0 QM reports.
•
Timing. NHC data are run once a quarter, whereas the CASPER MDS
3.0 QM data are updated more frequently. It is, therefore, likely that the
assessment database changed between the time the NHC statistics were
computed and the time the CASPER MDS 3.0 QM statistics were
computed. The CASPER MDS 3.0 QM statistics reflect all assessments
and assessment modifications that were submitted since the NHC
statistics were computed.
•
Reporting Periods. Every QM is based upon the selection of a target
assessment. For NHC, the target assessment must have a reference date
within the most recent 3 months for long-stay measures and the most
recent 6 months for short-stay measures. On the CASPER MDS 3.0 QM
Reports, you are allowed to customize the length of the selection period
(by adjusting the beginning and ending date of the report). If the selection
periods you select are different from those used for NHC, the results may
differ.
•
Averaging Across Quarters. The results that are presented on NHC are
averaged across several calendar quarters while the results on the
CASPER MDS 3.0 QM reports are for only a single reporting period.
•
Risk Adjustment. These adjusted percentages may not match the
percentages reported on NHC because of the way the risk adjustment
calculations are performed. One of the factors used in the risk adjustment
calculations is the national average for the QM at the time of calculation.
Since the calculations are usually performed at different times for the two
systems (see “Timing” above), the national means may differ and the
percentages may be different on the two sets of reports.
09/2015 v1.00
Certification And Survey Provider Enhanced Reports
CASPER Reporting MDS Provider User’s Guide
MDS 3.0 QM 11-20
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