New York State Department of Health

2018 Nursing Home Quality Initiative Methodology

Updated December 2018

  • Methodology is also available in Portable Document Format (PDF)

The 2018 Nursing Home Quality Initiative (NHQI) is comprised of three components: [1] the Quality Component (quality measures), [2] the Compliance Component (compliance with reporting), [3] and the Efficiency Component (potentially avoidable hospitalizations). The 2018 NHQI score is worth a maximum 100 points.

Quality Component (70 points)

Quality measures are calculated from MDS 3.0 data (2017 calendar year), the NYS employee flu vaccination data, and nursing home cost report data for the percent of contract/agency staff used and the rate of staffing hours per day.

  • The allotted 70 points for quality are distributed evenly for all quality measures. The 2018 NHQI includes 14 quality measures with each measure being worth a maximum of 5 points.
  • Four quarters of 2017 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 awarded points based on their 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 = 2017 (2016 measurement year)
Year 2 = 2018 (2017 measurement year)

For example, if 2017 NHQI performance (Year 1) is in the third quintile, and 2018 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.

Quality Measures (70 points)

The 14 quality measures for the 2018 NHQI are shown in the table below.

Table 1. Measures included in the Quality Component
Number Measure Measure Steward Data Source and
Measurement Period		 Scoring Method Notes Eligible for Improvement in 2018 NHQI
1 Percent of contract/agency staff used NYSDOH Nursing home cost report, 2017 calendar year for calendar filers and 2017 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 Rate of staffing hours per day NYSDOH Nursing home cost report, 2017 calendar year for calendar filers and 2017 fiscal year for fiscal filers, and MDS 3.0, 2017 calendar year Quintile   Yes
3 Percent of employees vaccinated for influenza NYSDOH Employee vaccination data submitted to the Bureau of Immunization through HERDS for the 2017–2018 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, 2017 calendar year Quintile Risk adjusted by the NYSDOH Yes
5 Percent of long stay residents who received the pneumococcal vaccine* CMS MDS 3.0, 2017 calendar year Quintile   Yes
6 Percent of long stay residents who received the seasonal influenza vaccine* CMS MDS 3.0, October 1, 2016 – June 30, 2017 Quintile   Yes
7 Percent of long stay residents experiencing one or more falls with major injury CMS MDS 3.0, 2017 calendar year Quintile   Yes
8 Percent of long stay residents who have depressive symptoms CMS MDS 3.0, 2017 calendar year Quintile   Yes
9 Percent of long stay low risk residents who lose control of their bowel or bladder CMS MDS 3.0, 2017 calendar year Quintile   Yes
10 Percent of long stay residents who lose too much weight CMS MDS 3.0, 2017 calendar year Quintile Risk adjusted by the NYSDOH Yes
11 Percent of long stay residents with dementia who received an antipsychotic medication PQA MDS 3.0, 2017 calendar year Quintile   Yes
12 Percent of long stay residents who self–report moderate to severe pain CMS MDS 3.0, 2017 calendar year Quintile Risk adjusted by the NYSDOH Yes
13 Percent of long stay residents whose need for help with daily activities has increased CMS MDS 3.0, 2017 calendar year Quintile   Yes
14 Percent of long stay residents with a urinary tract infection CMS MDS 3.0, 2017 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.

Changes to the Compliance Component
  • CMS Five–Star Quality Rating for Health Inspections
    • Due to the implementation of the new long–term care survey process on November 28, 2017, surveys conducted between November 28, 2017 and November 27, 2018 will not be incorporated into the CMS Five–Star Quality Rating System for 12 months.
    • Per CMS, beginning in early 2018, the Five–Star Quality Rating for Health Inspections will be based on the two most recent cycles of findings for both standard health inspection surveys and complaint inspections. This is a change from CMS' previous methodology, which incorporated the three most recent cycles of findings. This Five–Star Quality Rating for health inspections will be calculated from the two most recent surveys conducted prior to November 28, 2017.
    • When the ratings become available in early 2018, NYSDOH will perform additional analyses to determine how the ratings will be used in the 2018 NHQI.
    • For more information, please see the November 24, 2017 CMS Memorandum.

The three compliance measures for the 2018 NHQI are detailed in the descriptions and in the table below.

  • CMS Five–Star Quality Rating for Health Inspections (regionally adjusted)
    • 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 NYSDOH Bureau of Immunization for the 2017-2018 influenza season by the deadline of May 1, 2018 is worth five points.
    • Submission of certified and complete 2017 nursing home cost reports to the NYSDOH by the deadlines as specified by the Bureau of Long Term Care Reimbursement, Division of Finance and Rate Setting, is worth five points.
Table 2. Measures included in the Compliance Component
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, pending additional analyses per CMS changes 5 stars=10 points
4 stars=7 points
3 stars=4 points
2 stars=2 points
1 star=0 points
2 Timely submission of employee influenza vaccination data NYSDOH Employee influenza vaccination data submitted to the Bureau of Immunization through HERDS for the 2017–2018 influenza season Five points for submission by the deadline
3 Timely submission of certified and complete nursing home cost reports NYSDOH Nursing home cost report, 2017 calendar year for calendar filers and 2017 fiscal year for fiscal filers Five points for timely, certified and complete submission of the 2017 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.
Table 3. Measures included in the Efficiency Component
Number Measure Measure Steward Data Source and
Measurement Period		 Scoring Method
1 Potentially Avoidable Hospitalizations CMS/NYSDOH MDS 3.0 and SPARCS, 2017 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.

Table 4. Calculating the overall score with and without small sample size
  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 ratio
(points/maximum)		 .80 .89
Final 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 (2017) and June 30 of the reporting year (2018).
  • 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 (2018) 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 2017 or 2018, prior to the final calculation of the 2018 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

Schedule for the 2018 NHQI

  • May 1, 2018 – Employee influenza vaccination data due
  • Nursing home certified and complete cost reports due for calendar and fiscal year filers by deadlines specified by the Bureau of Long Term Care Reimbursement, Division of Finance and Rate Setting
  • December 2018 – NYS DOH will release preliminary results on the Health Commerce System for feedback
  • January 2019 – NYS DOH will release the final results of the 2018 NHQI on the Health Commerce System and on Health Data NY

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 used in the 2018 NHQI can be found in the MDS 3.0 Quality Measures User´s Manual, Version 11.0.

Measure specifications for the Pharmacy Quality Alliance's percent of long stay residents with dementia who received an antipsychotic medication measure can be found here.