Quality Indicators: Original CHSRA QIs

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QI Versions: MDS+ versus MDS 2.0 and Variants

The quality indicators (QIs) originally were developed for use with CMS's Multistate Nursing Home Case Mix and Quality Demonstration project. States participating in the quality component of that demonstration (Kansas, Maine, Mississippi, and South Dakota) used an expanded form of the Minimum Data Set (MDS) known as the MDS+.

In order to allow use of the QIs beyond the demonstration, and in recognition of CMS's planned move from the MDS+ to the MDS version 2.0, it was necessary to define QIs using the MDS 2.0. It is not possible to directly apply the QIs as defined for the MDS+ to the MDS 2.0.

The translation of the QIs for the MDS 2.0 faced two significant challenges. First, there were some significant differences between the MDS+ and the MDS 2.0. Some items were modified or redefined, others were deleted and replaced with entirely new items. An example of an item that was modified is the item related to the presence of contractures. The MDS+ defined contractures (items H5b-f) as "restriction of full functional range of motion of any joint due to any cause" (MDS+ Manual, page 6-53). The MDS 2.0 moved away from the concept of contractures to focus on range of motion. Thus, the MDS 2.0 offers items G4a-f, as functional limitations in range of motion. This item captures "the presence of (A) functional limitation in range of joint motion or (B) loss of voluntary movement," and both are defined as limitations that "[interfere] with daily functioning . . . or [place] the resident at risk of injury" (MDS 2.0 Manual, page 3-95). An example of an item that was replaced by an entirely new item is the MDS+ item E1f, a checkbox indicating suicidal thoughts or actions. The MDS 2.0 has no similar item. Items that changed or that did not exist on the MDS 2.0 affected our ability to define QIs. While most QI definitions are the same regardless of the assessment form used, some QI definitions have been modified to reflect the differences in the data available from the MDS 2.0.

The second major difference between the MDS+ and the MDS 2.0 was the frequency and comprehensiveness of the data collected. In all cases, the data was collected upon initial admission to the facility; at readmission following temporary discharge to a hospital, other care facility, or home; and on a quarterly basis. (A small number of assessments were conducted for other reasons, in some states.) While the assessment schedule was the same, within the demonstration states the full set of data were obtained at each assessment. Currently states are using the MDS 2.0, however, there are a variety of assessment options. The minimal requirement is that a complete assessment be conducted upon admission, readmission, and annually; quarterly assessments may collect only a subset of the information collected at other times. Thus, the information needed to define a given QI may be available when a complete assessment is completed, but not when the data come from the partial quarterly assessment. Since the most frequent reason for completing an MDS assessment is for a quarterly update, this places a strong limitation on the calculation of the QIs.

There are other variations of the QIs depending upon the types of quarterly assessments used (e.g., RUGS III or a full assessment) or if supplemental case mix information (Section T of the MDS is collected or Section U, medication information is used). For copies of other matrices defined by these other assessments or supplemental information please contact Lorraine Roberts.