Nursing Home Quality Initiative 2015 Methodology

The 2015 Nursing Home Quality Initiative (NHQI) is comprised of three areas: [1] quality measures (Quality Component), [2] compliance with reporting (Compliance Component), [3] the Efficiency Component. The 2015 NHQI is worth a maximum 100 points.

Quality Component (70 points)

Quality measures are calculated from MDS 3.0 data, the NYS employee flu vaccination data, nursing home cost report data for the percent of contract/agency staff used, and the CMS five-star quality rating for staffing.

  • The allotted 70 points for quality are distributed evenly for all quality measures. The 2015 NHQI includes 14 quality measures with each measure being worth a maximum of 5 points.
  • Four quarters of 2014 MDS 3.0 data are used.
  • The quintiles are based on the same measurement year of the results. Therefore only a certain number of nursing homes are able to achieve these quintiles for each measure. The results are not rounded until after determining the quintile for measures. For measures with very narrow ranges of performance, two facilities may be placed in different quintiles and receive different points, but after rounding, the facilities may have the same rate.
  • For quality measures that are based on the quintile distribution, nursing homes will be rewarded for achieving high performance as well as improvement from previous years' performance. Note that improvement points will not apply to quality measures that are based on threshold values. See the Quality Point Grid for Attainment and Improvement below. Assuming each quality measure is worth 5 points, the distribution of points based on two years of performance is demonstrated in the grid.

Quality Point grid for Attainment and Improvement

Year 1 Performance
Year 2
Performance
Quintiles 1 2 3 4 5
1 (best) 5 5 5 5 5
2 3 3 4 4 4
3 1 1 1 2 2
4 0 0 0 0 1
5 0 0 0 0 0

Year 1=2014     Year 2=2015

For example, if 2014 NHQI performance (Year 1) is in the third quintile, and 2015 NHQI performance (Year 2) is in the second quintile, the facility will receive 4 points for the measure. This is 3 points for attaining the second quintile and 1 point for improvement from the previous year's third quintile.

Changes to the Quality Component

  • Long stay resident antipsychotic medication measure
    • The CMS antipsychotic measure has been replaced by the Pharmacy Quality Alliance measure for Antipsychotic use in Persons with Dementia. This is a National Quality Forum-endorsed measure which focuses on residents with dementia who have a history of receiving an antipsychotic medication. Measure specifications can be found at http://pqaalliance.org/measures/default.asp.
  • Long stay resident pneumococcal vaccination measure
    • Preliminary 2014 MDS data shows that the statewide average for the percent of long stay residents who received the pneumococcal vaccine is below 85%. Therefore, this measure will be assigned points based on quintiles rather than a threshold value of 85%. More nursing homes benefit from the quintile method.
Number Measure Measure Steward Data Source and Measurement Period Scoring Method Notes Eligible for Improvement in 2015 NHQI
1 Percent of contract/agency staff used NYS DOH Nursing home cost report, 2014 calendar year for calendar filers and 2014 fiscal year for fiscal filers Threshold Maximum points are awarded if the rate is less than 10%, and zero points if the rate is 10% or greater. No
2 CMS five-star quality rating for staffing CMS CMS Five-Star Quality Ratings as of April 1, 2015 5 stars=5 points
4 stars=3 points
3 stars=1 point
2 stars=0 points
1 star=0 points		 No
3 Percent of employees vaccinated for influenza NYS DOH Employee vaccination data submitted to the Bureau of Immunization through HERDS for the 2014-2015 influenza season Threshold Maximum points are awarded if the rate is 85% or greater, and zero points if the rate is less than 85% No
MDS 3.0 Quality Measures
4 Percent of long stay high risk residents with pressure ulcers CMS MDS 3.0, 2014 calendar year Quintile Risk adjusted by the New York State Department of Health (NYS DOH) Yes
5 Percent of long stay residents who received the pneumococcal vaccine* CMS MDS 3.0, 2014 calendar year Quintile No
6 Percent of long stay residents who received the seasonal influenza vaccine* CMS MDS 3.0, 2014 calendar year Quintile Yes
7 Percent of long stay residents experiencing one or more falls with major injury CMS MDS 3.0, 2014 calendar year Quintile Yes
8 Percent of long stay residents who have depressive symptoms CMS MDS 3.0, 2014 calendar year Quintile Yes
9 Percent of long stay low risk residents who lose control of their bowel or bladder CMS MDS 3.0, 2014 calendar year Quintile Yes
10 Percent of long stay residents who lose too much weight CMS MDS 3.0, 2014 calendar year Quintile Risk adjusted by the NYS DOH Yes
11 Antipsychotic use in persons with dementia Pharmacy Quality Alliance (PQA) MDS 3.0, 2014 calendar year Quintile No
12 Percent of long stay residents who self-report moderate to severe pain CMS MDS 3.0, 2014 calendar year Quintile Risk adjusted by the NYS DOH Yes
13 Percent of long stay residents whose need for help with daily activities has increased CMS MDS 3.0, 2014 calendar year Quintile Yes
14 Percent of long stay residents with a urinary tract infection CMS MDS 3.0, 2014 calendar year Quintile Yes

*a higher rate is better

Compliance Component (20 points)

The compliance component consists of three areas: CMS' five-star quality rating for health inspections, timely submission of nursing home certified cost reports, and timely submission of employee influenza immunization data.

  • CMS Five-Star Quality Rating for Health Inspections (regionally adjusted)
    • CMS´ facility ratings for the health inspections domain are based on the number, scope, and severity of the deficiencies identified during the three most recent annual inspection surveys, as well as substantiated findings from the most recent 36 months of complaint investigations. All deficiency findings are weighted by scope and severity. The CMS rating also takes into account the number of revisits required to ensure that deficiencies identified during the health inspection survey have been corrected.
    • The health inspection survey scores from CMS will be used to calculate cut points for each region in the state. Regions include the Metropolitan Area, Western New York, Capital District, and Central New York. Per CMS' methodology, the top 10% of nursing homes will receive five stars, the middle 70% will receive four, three, or two stars, and the bottom 20% will receive one star. Each nursing home will be awarded a Five-Star Quality Rating based on the cut points calculated from the health inspection survey scores within its region. Ten points are awarded for obtaining five stars or the top 10 percent (lowest 10 percent in terms of health inspection deficiency score). Seven points for obtaining four stars, four points for obtaining three stars, two points for obtaining two stars, and zero points for one star.
  • Timely submission measures
    • Submission of employee influenza vaccination data to the NYS DOH Bureau of Immunization by the deadline of May 1, 2015 is worth five points.
    • Submission of certified and complete 2014 nursing home cost reports to the NYS DOH by the deadlines of August 14, 2015 for calendar year filers, and November 13, 2015 for fiscal year filers, is worth five points.

The three compliance measures for the 2015 NHQI are shown in the table below.

Number Measure Measure Steward Data Source and Measurement Period Scoring Method
1 CMS Five-Star Quality Rating for Health Inspections (regionally adjusted) CMS CMS health inspection survey scores as of April 1, 2015 5 stars=10 points
4 stars=7 points
3 stars=1 point
2 stars=0 point
1 star=0 points
2 Timely submission of employee influenza vaccination data NYS DOH Employee influenza vaccination data submitted to the Bureau of Immunization through HERDS for the 2014-2015 influenza season Five points for submission by the deadline
3 Timely submission of certified and complete nursing home cost reports NYS DOH Nursing home cost report, 2014 calendar year for calendar filers and 2014 fiscal year for fiscal filers Five points for timely, certified and complete submission of the 2014 cost report

Efficiency Component (10 points)

  • To align with the other CMS quality measures, the Potentially Avoidable Hospitalizations rate will be calculated for each quarter, then averaged to create an annual average.
  • The PAH measure is risk adjusted.
Number Measure Measure
Steward		 Data Source and
Measurement Period		 Scoring Method
1 Potentially
Avoidable
Hospitalizations		 CMS/NYS DOH MDS 3.0 and SPARCS,
2014 calendar year		 Quintile 1=10 points
Quintile 2=8 points
Quintile 3=6 points
Quintile 4=2 points
Quintile 5=0 points

Scoring

The facility´s overall score will be calculated by summing the points for each measure in the NHQI. In the event that a measure cannot be used due to small sample size or unavailable data, the maximum attainable points will be reduced for that facility. For example, if a facility has a small sample size on two of its quality measures (each 5 points), the maximum attainable points will be 90 rather than 100. The sum of its points will be divided by 90 to calculate its total score. The example below provides a mathematical illustration of this method.

Facility A
no small
sample size		 Facility B
small sample size
on two quality measures
Sum of points 80 80
Maximum points attainable 100 90
Score (points/maximum) .80 .89
Score × 100 80% 89%

Ineligibility for NHQI Ranking

Due to the severity of letter J, K, and L health inspection deficiencies, receipt of a deficiency is incorporated into the NHQI. Nursing homes that receive one or more of these deficiencies are not eligible to be ranked into overall quintiles. J, K, and L deficiencies indicate a Level 4 immediate jeopardy, which is the highest level of severity for deficiencies on a health inspection. Immediate jeopardy indicates that the deficiency resulted in noncompliance and immediate action was necessary, and the event caused or was likely to cause serious injury, harm, impairment or death to the resident(s).

  • Deficiency data shows a J/K/L deficiency between July 1 of the measurement year (2014) and June 30 of the reporting year (2015).
  • Deficiencies will be assessed on October 1 of the reporting year to allow a three-month window for potential Informal Dispute Resolutions (IDR) to process.
  • Any new J/K/L deficiencies between July 1 and September 30 of the reporting year (2015) will not be included in the current NHQI; they will be included in the next NHQI cycle.

Nursing Home Exclusions from NHQI

The following types of facilities will be excluded from the NHQI and will not contribute to the pool or be eligible for payment:

  • Non-Medicaid facilities
  • Any facility designated by CMS as a Special Focus Facility at any time during 2014 or 2015, prior to the final calculation of the 2015 NHQI
  • Specialty facilities
  • Specialty units within a nursing home (i.e. AIDS, pediatric specialty, traumatic brain injury, ventilator dependent, behavioral intervention)
  • Continuing Care Retirement Communities
  • Transitional Care Units

NYS DOH Development of Staffing Measures

Two new NYS DOH staffing measures will be included in the release of the 2015 NHQI results for benchmarking purposes only. These measures will not be used in the scoring algorithm for the 2015 NHQI. Each nursing home's 2015 NHQI results will include the values and quintile placements for the measures in the table below. NYS DOH continues to communicate with the NHQI workgroup regarding testing and evaluation of these measures. Nursing homes are encouraged to compare these measures to their cost report data. Other projects that nursing homes may be involved in, such as Advancing Excellence in America's Nursing Homes, produce similar measures that may be comparable. Please contact the NHQI email address with questions and feedback. The measure descriptions and data sources are described below.

Number Measure Measure
Steward		 Data Source and
Measurement Period		 Measure description
1 Staffing rate (nurse hours per day for RNs, LPNs, and Aides) NYS DOH 2014 nursing home cost report and 2014 MDS 3.0
  • The hours reported are taken from the hours worked field for RNs, LPNs, and Aides on the nursing home cost report.
  • The hours expected are computed using the MDS RUG distribution of the nursing home residents and the CMS Time Staff Measurement Studies.
  • The hours reported are divided by the hours expected and multiplied by the statewide average to create a case-mix-adjusted staffing rate.
2 Percent of staff turnover NYS DOH 2014 nursing home cost report
  • The total number of RNs, LPNs, and Aides at the end of each quarter, and the total number of RNs, LPNs, and Aides terminated at the end of the year will be taken from the nursing home cost report.
  • The total number of above-mentioned staff members terminated will be divided by the average number of staff members per quarter to calculate the percent of staff turnover.
  • Contract and per diem staff are excluded from this measure.

Schedule for the 2015 NHQI

  • May 1, 2015 - Employee influenza vaccination data due
  • August 14, 2015 - Nursing home certified and complete cost reports due for calendar year filers
  • November 13, 2015 - Nursing home certified and complete cost reports due for fiscal year filers
  • November 2015 - NYS DOH will release preliminary results on the Health Commerce System for feedback
  • December 2015 - NYS DOH will release the final results of the 2015 NHQI on the Health Commerce System and on Health Data NY
  • January 2016 - NYS DOH will release the methodology for the 2016 NHQI

For more information about the NHQI methodology, please contact the Office of Quality and Patient Safety at NHQP@health.ny.gov.

Measure specifications for the CMS Quality Measures can be found in the MDS 3.0 QM User's Manual, Version 8.0 at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html.