Archived: Quality Measures

Below is an archive of previous versions of the Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual and related documents. These previous versions are posted for reference only and should not be considered a current reference for the MDS 3.0 QM User’s Manual. Active and upcoming versions of MDS 3.0 QM User’s Manual are posted on the NHQI Quality Measures page. 

December 22, 2023

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

In response to provider questions related to the Minimum Data Set (MDS) 3.0 Quality Measures (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 October 1, 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 QM 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 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 QMs 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:

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.

January 4, 2022

MDS 3.0 QM User’s Manual Version 15.0 Now Available

The Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual V15.0 and accompanying Risk Adjustment Appendix File for MDS 3.0 QM User’s Manual V15.0 have been posted. The MDS 3.0 QM User’s Manual V15.0 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 V14.0. The MDS 3.0 QM User’s Manual V15.0 can be found in the Downloads section of this webpage. The logistic regression coefficients used to risk adjust the Percent of Residents Who Made Improvements in Function (Short-Stay [SS]), Percent of Residents Whose Ability to Move Independently Worsened (Long-Stay [LS]), and Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder (LS) measures have been updated using Q4 2019 data. These coefficients were previously contained in Chapter 4 of the MDS QM User’s Manual V14.0 but have been moved to the Risk Adjustment Appendix File for MDS 3.0 Quality Measure User’s Manual V15.0.

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

MDS QM User’s Manual V15 Effective 01-01-2022 (ZIP) includes the MDS 3.0 QM User’s Manual V15.0, which 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 QM User’s Manual V15 Effective 01-01-2022 (ZIP) also includes the Risk Adjustment Appendix File for MDS 3.0 Quality Measure User’s Manual V15.0, which contains the logistic regression coefficients used to risk adjust the Percent of Residents Who Made Improvements in Function (SS), Percent of Residents Whose Ability to Move Independently Worsened (LS), and Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder (LS) measures. MDS 3.0 QM User’s Manual V15 Effective 01-01-2022 (ZIP) is available under the Downloads section of this webpage.

October 19, 2020

MDS 3.0 QM User’s Manual Version 14.0 Now Available

The Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual V14.0 has been posted. The MDS 3.0 QM User’s Manual V14.0 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 V13.0. The MDS 3.0 QM User’s Manual V14.0 can be found in the Downloads section of this webpage, grouped with other Skilled Nursing Facility (SNF) and Nursing Home user’s manuals in a zip file titled Users-Manuals-Updated-10-19-2020. The zip file titled User Manuals - Updated 01-21-2020 (ZIP) containing the MDS 3.0 QM User’s Manual V13.0 has been moved to the Quality Measures Archive webpage.

The zip file titled Users-Manuals-Updated-10-19-2020 includes five files:

1. MDS 3.0 QM User’s Manual V14.0 (MDS-3_0-QM-USERS-MANUAL-v14_0.pdf) contains detailed specifications for the MDS 3.0 quality measures, 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.
2. Nursing Home Compare Claims-based Quality Measure Technical Specifications (Nursing Home Compare Claims-based Measures Tech Specs.pdf) contains detailed technical specifications for all nursing home quality measures.
3. Nursing Home Compare Quality Measures Technical Specifications Appendix (APPENDIX - Claims-based measures Technical Specifications.pdf) contains tables and appendices related to the Nursing Home Compare Claims-based Quality Measures.
4. Skilled Nursing Facility Quality Reporting Program (SNF QRP) Measure Calculations and Reporting User’s Manual V3.0 (SNF Measure Calculations and Reporting User's Manual V3.0_FINAL_508C_081419.pdf) contains detailed specifications for all SNF QRP Quality Measures.
5. SNF QRP Measure Calculations and Reporting User’s Manual Version 3.0.1 (SNF-QRP-QM-Users-Manual-V3_0_1-Addendum-Change-Table.pdf) contains appendices for the SNF QRP Measure Calculations and Reporting Manual V3.0, including a risk adjustment appendix and Hierarchical Condition Category (HCC) crosswalks.

January 29, 2020

MDS 3.0 QM User’s Manual Version 13.0 Now Available

The MDS 3.0 QM User’s Manual V13.0 and Quality Measure Reporting Module Table V1.8 have been posted. The MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. The MDS 3.0 QM User’s Manual V13.0 can be found in the Downloads section of this webpage and the MDS 3.0 QM User’s Manual V12.1 has been moved to the Quality Measures Archive webpage. The Quality Measure Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module, with a unique CMS identification number specified for each QM. The Quality Measure Reporting Module Table V1.8 can be found in the Downloads section of this webpage and the Quality Measure Reporting Module Table V1.7 has been moved to the Quality Measures Archive webpage MDS 3.0 QM User’s Manual have been posted:

1. MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. MDS 3.0 QM User’s Manual V13.0 is available under the Downloads section of this webpage. It is included in the zip file titled User Manuals - Updated 01-21-2020 (ZIP).
2. Quality Measure Identification Number by CMS Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. A unique CMS identification number is specified for each QM. The table is available under the Downloads section of this webpage. 

October 08, 2019

Nursing Home Quality Measure Changes

 The following nursing home quality measures have been removed:

• Percentage of short-stay residents who report moderate to severe pain.
• Percentage of long-stay residents who report moderate to severe pain.

This change supports the federal initiative to reduce opioid utilization by seeking to prevent a potential scenario where the performance of a facility on the pain quality measures may inappropriately contribute to their decision to seek the administration of an opioid. The active nursing home measures are listed below.

MDS 3.0 QM User’s Manual Version 12.1 Now Available

The MDS 3.0 QM User’s Manual Version 12.1 has been posted. The MDS 3.0 QM User’s Manual V12.1 contains detailed specifications for the MDS 3.0 quality measures. The MDS 3.0 QM User’s Manual V12.1 can be found in the Downloads section of this page and the MDS 3.0 QM User’s Manual V12.0 has been moved to the Quality Measures Archive page.

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

1. MDS 3.0 QM User’s Manual V12.1 contains detailed specifications for the MDS 3.0 quality measures. MDS 3.0 QM User’s Manual V12.1 is available under the Downloads section of this page.
2. Quality Measure Identification Number by CMS Reporting Module Table V1.7 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module.  A unique CMS identification number is specified for each QM. The table is available under the Downloads section of this page. 

November 29, 2017

CMS held a webinar on the Meaningful Measures Initiative on November 28. To review the presentation, go here. 

Nursing home quality measures have four intended purposes:

• To give you information about the quality of care at nursing homes in order to help you choose a nursing home for yourself or others;
• To give you information about the care at nursing homes where you or family members already live;
• To give you information to facilitate your discussions with the nursing home staff regarding the quality of care; and
• To give data to the nursing home to help them in their quality improvement efforts.

The nursing home quality measures come from resident assessment data that nursing homes routinely collect on the residents at specified intervals during their stay. These measures assess the resident's physical and clinical conditions and abilities, as well as preferences and life care wishes. These assessment data have been converted to develop quality measures that give consumers another source of information that shows how well nursing homes are caring for their resident's physical and clinical needs.

The current quality measures have been chosen because they can be measured and don't require nursing homes to prepare additional reports. They are valid and reliable. However, they are not benchmarks, thresholds, guidelines, or standards of care. The quality measures are based on care provided to the population of residents in a facility, not to any individual resident, and are not appropriate for use in a litigation action.

These quality measures were selected because they are important. They show ways in which nursing homes are different from one another. There are things that nursing homes can do to improve their quality measure percentages. The quality measures have been validated and are based on the best research currently available. As this research continues, scientists will keep improving the quality measures on this website.

The quality measure short stay and long stay definitions are:

• The short stay resident quality measures show the average quality of resident care in a nursing home for those who stayed in a nursing home for 100 days or less or are covered under the Medicare Part A Skilled Nursing Facility (SNF) benefit. Short-stay residents often are those recovering from surgery or being discharged from a hospital stay. Many short-stay residents get care in a nursing home until they’re able to go back home or to the community.
• The long stay resident quality measures show the average quality of care for certain care areas in a nursing home for those who stayed in a nursing home for 101 days or more. Residents in a nursing home for a long-stay are usually not healthy enough to leave a nursing home and can’t live at home or in a community setting. These residents may be older and have more serious health issues.