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Data and Measurement

Are you looking for your facility's performance data report, or for help in interpreting it?

Advancing Excellence Campaign

For standardized process measures like rehospitalization, person-centered care, and consistent assignment, use the Advancing Excellence tracking tools to establish your baseline and track your improvement over time. You may also submit your data monthly on the AE website in order to compare your progress with others in the state and nationally.

Read about the nine goals of the Advancing Excellence Campaign.
 

National Healthcare Safety Network (NHSN)


You can make a difference!

(And we can help)

Qualis Health is offering a limited number of nursing homes free education and consultation to:

  • Determine your baseline rates—which helps identify the best areas to focus your process improvement efforts
     
  • Use the NHSN reporting system—which may better position your nursing home for hospital partnerships, and helps you prepare for a future where all nursing homes may be required to submit data to NHSN
     
  • Support your infection prevention officer—CMS’ proposed rule requires every nursing home to designate a staff person in this role
     
  • Implement best-practices for infection prevention and antimicrobial stewardship—which protects your business, your staff, and your residents

 

 

To sign up for our assistance, complete this form.

 


See clinical resources for infection prevention.

WW 2 era RN with cape

Data submitted to the NHSN are used by the CDC to prepare national and statewide analyses of various healthcare-associated infections.

The data are not released to government agencies. Participating nursing homes have the sole authority to grant rights to others (such as Qualis Health) to view their submissions.

 

 

National Nursing Home Quality Care Collaborative (NNHQCC) Composite Score

The NNHQCC’s composite score is comprised of 13 NQF-endorsed, long-stay quality measures that represent larger systems within the long-term care setting.

Qualis Health reports individual composite scores along with aggregate comparisons to each NHQCC particpant. Other nursing homes can calculate their own score by following these instructions.
 

Quality Measure Reports

Nursing homes regularly submit clinical Quality Measure (QM) data to CMS.  The data are accessible via the Minimum Data Set (MDS) database, and some of those measures are published quarterly for public use on Nursing Home Compare.

The QIES/CASPER system includes a report that summarizes your QM results and includes state and national comparisons. (Your CASPER data is updated more frequently than the state and national comparisons.) Chapter 11 of the CASPER User's Guide describes how to access this report.

You may also choose to track your own data from weekly logs and other in-house sources. Qualis Health has developed a Run Chart tool to make it easier for you to track and compare your data over time.

Measure Specifications

For detailed definitions of the numerator and denominator used in each QM, download CMS' most current User Guide (listed near the bottom of their webpage)
 

Race, Ethnicity, and Primary Language

Disparities are evident throughout the nation's healthcare system. Are you collecting and analyzing data about race and language along with other quality measures? Learn how and why.