Quality Measures

Quality Measures

Now available! Our new Provider Data Catalog makes it easier for you to search and download our publicly reported data. We’ve also improved Medicare’s compare sites.

What's New

December 22, 2023

MDS 3.0 QM User's Manual v16.0 Effective 10-1-2023 and Associated User Manual Files – Corrected Manual Now Available 

In response to provider questions related to the MDS 3.0 QM User’s Manual posted on September 20, 2023, an updated MDS 3.0 QM User’s Manual v16.0, effective 10-1-2023, is now posted. Additionally, the updated .zip file titled MDS 3.0 QM User's Manual v16.0 Effective 10-1-2023 and Associated User Manual Files.zip includes a complete set of six files:

  1. MDS 3.0 QM User’s Manual V16.0 (MDS-3.0-QM-USERS-MANUAL-v16.pdf) contains detailed specifications for the MDS 3.0 quality measures effective October 1, 2023, as well as the Quality Measure Reporting Module Table that documents the Centers for Medicare & Medicaid Services (CMS) quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. 

    The MDS 3.0 QM User’s Manual V16.0 has been updated to remediate a previous error in the Exclusions list of the (i) Percent of Residents Who Used Antianxiety or Hypnotic Medication (LS) and (ii) Prevalence of Antianxiety/Hypnotic Use (LS) measures. Rather than excluding both N0415B1 = [-] and N0415D1 = [-] for assessments with target dates on or after 10/01/2023, the previous specifications duplicated MDS v1.18.11 item N0415B1 = [-] as an exclusion for assessments with target dates on or after 10/01/2023.  Additionally, where applicable, the file was edited for grammar and CBE endorsement status. 

  2. Risk Adjustment Appendix File for MDS 3.0 Quality Measure User’s Manual V15.0 (Risk-Adjustment-Appendix-File-for-MDS-3.0-Quality-Measures-User's-Manual-V15.xlsx) contains the logistic regression coefficients used for risk adjustment.

    Note: A new Risk Adjustment Appendix file to accompany V16.0 of the MDS 3.0 QM User’s Manual is not available as there is not enough data to calculate coefficients for measures which utilize Section GG data in risk-adjustment. An updated Risk Adjustment Appendix file will be published when technically feasible. In the meantime, readers can continue to refer to V15.0 of the Risk Adjustment Appendix for the most current risk adjustment coefficients for the applicable measures.

  3. Nursing Home Compare Claims-based Quality Measure Technical Specifications (Nursing Home Compare Claims-based Measures Tech Specs 2023 Update 03-20-2023.pdf) contains detailed technical specifications for all nursing home claims-based quality measures.
  4. Nursing Home Compare Quality Measures Technical Specifications Appendix (APPENDIX - Claims-based Measures Technical Specifications Updates 03-20-23.pdf) contains tables and appendices related to the Nursing Home Compare Claims-based Quality Measures. 
  5. Skilled Nursing Facility Quality Reporting Program (SNF QRP) Measure Calculations and Reporting User’s Manual V5.0 (snf-qm-calculations-and-reporting-users-manual-v5.0.pdf) contains detailed specifications for all SNF QRP Quality Measures effective October 1, 2023.
  6. Risk Adjustment Appendix File for the SNF QRP Measure’s Calculations and Reporting User’s Manual V5.0 (Risk-Adjustment-Appendix-File-for-SNF-Effective-10-01-2023.xlsx) contains risk-adjustment values used to calculate SNF QRP risk-adjusted quality measures.

The updated .zip file is available in the Downloads section of this webpage.

September 21, 2023

Public Reporting Timeline for NHQI Measures Impacted by the MDS 3.0 G-GG Transition

Effective October 1, 2023, Minimum Data Set (MDS) Section G: Functional Status will be replaced with Section GG: Functional Abilities and Goals. This transition will significantly impact the specifications of the following Nursing Home Quality Initiative (NHQI) quality measures (QMs):

  • Percentage of Residents Who Made Improvements in Function (Short Stay)
  • Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (Long Stay)
  • Percent of Residents Whose Ability to Move Independently Worsened (Long Stay)
  • Percent of High-Risk Residents with Pressure Ulcers (Long Stay)
  • Percent of Low-Risk Residents Who Lose Control of Their Bowel and Bladder (Long Stay)

To address the impact of this Section G to GG transition on the 2024 Nursing Home Care Compare public reporting schedule, the Centers for Medicare & Medicaid Services (CMS) will freeze (hold constant) the aforementioned QMs on Nursing Home Care Compare in April 2024. In October 2024, CMS will replace the Percentage of Residents Who Made Improvements in Function (Short Stay) measure with the new Discharge Function Score measure which was finalized in the FY2024 SNF PPS Final Rule for use in the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) and the SNF Value Based Purchasing (VBP) program. The remaining four measures will continue to be frozen until January 2025 while the data for the equivalent measures are collected.  

Please see the Updates to Nursing Home Care Compare Staffing and Quality Measures Quality, Safety & Oversight Group (QSO) memo for more information.

For more information on the new and re-specified QMs please see the MDS 3.0 QM User’s Manual V16.0, which can be found in the Downloads section of this webpage.

September 20, 2023

MDS 3.0 QM User’s Manual V16.0– Now Available

The Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual Version (V)16.0 is now available. The MDS 3.0 QM User’s Manual V16.0 contains detailed specifications for the MDS 3.0 quality measures and includes a Notable Changes section that summarizes the major changes from MDS 3.0 QM User’s Manual V15.0.

Major changes to the manual involve the re-specification and replacement of QMs that use items impacted by the MDS transition from v1.17.2 to v1.18.11, effective October 1, 2023 (i.e., Section G items are replaced by Section GG items).

The MDS 3.0 QM User’s Manual V16.0 can be found in the Downloads section of this webpage and the MDS 3.0 QM User’s Manual V15.0 has been moved to the Quality Measures Archive webpage.

One file related to the MDS 3.0 QM User’s Manual has been posted:

  1. MDS-3.0-QM-USER'S-MANUAL-v16.0.pdf contains detailed specifications for the MDS 3.0 quality measures, as well as the Quality Measure Reporting Module Table that documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. MDS-3.0-QM-USER'S-MANUAL-v16.0.pdf is available under the Downloads section of this webpage.

The current nursing home quality measures are:

Short Stay Quality Measures

  • Percent of Short-Stay Residents Who Were Re-Hospitalized after a Nursing Home Admission
  • Percent of Short-Stay Residents Who Have Had an Outpatient Emergency Department Visit
  • Percent of Residents Who Newly Received an Antipsychotic Medication
  • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
  • Percent of Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
  • Percent of Residents Who Received the Seasonal Influenza Vaccine*
  • Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine*
  • Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine*
  • Percent of Residents Who Were Assessed and Appropriately Given the Pneumococcal Vaccine
  • Percent of Residents Who Received the Pneumococcal Vaccine*
  • Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine*
  • Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Pneumococcal Vaccine*
  • Discharge Function Score

* These measures are not publicly reported but available for provider preview.

Long Stay Quality Measures

  • Number of Hospitalizations per 1,000 Long-Stay Resident Days
  • Number of Outpatient Emergency Department Visits per 1,000 Long-Stay Resident Days
  • Percent of Residents Who Received an Antipsychotic Medication
  • Percent of Residents Experiencing One or More Falls with Major Injury
  • Percent of High-Risk Residents with Pressure Ulcers
  • Percent of Residents with a Urinary Tract Infection
  • Percent of Residents Who Have or Had a Catheter Inserted and Left in Their Bladder
  • Percent of Residents Whose Ability to Walk Independently Worsened
  • Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased
  • Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
  • Percent of Residents Who Received the Seasonal Influenza Vaccine*
  • Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine*
  • Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine*
  • Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine
  • Percent of Residents Who Received the Pneumococcal Vaccine*
  • Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine*
  • Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Pneumococcal Vaccine*
  • Percent of Residents Who Were Physically Restrained
  • Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder
  • Percent of Residents Who Lose Too Much Weight
  • Percent of Residents Who Have Depressive Symptoms
  • Percent of Residents Who Used Antianxiety or Hypnotic Medication
  • Percent of Residents with Pressure Ulcers
  • Percent of Residents with New ore Worsened Bowel or Bladder Incontinence

* These measures are not publicly reported but available for provider preview.

Quality measure specifications are available in the QM Users’ Manual download file, which can be found under the Downloads section below. A sub-group of quality measures are incorporated into the Five-Star Quality Rating System and used to determine scoring for the quality measures domain on Nursing Home Compare.

Page Last Modified:
01/12/2024 10:41 AM