Answer

1A) Application 1:  Measuring Quality Guidelines

Quality measurement in healthcare involves using data for evaluation of the progress of health plans while given set standards are used as a reference. Quality measurement helps healthcare administrators to establish the performance of their organizations and thereby propose suitable care improvement strategies. Quality improvement initiatives identify gaps within the nursing practice and provide possible solutions to the factors that might compromise quality care and patient safety. Quality measures can be either based on short-stay residents or long-stay residents. This paper is purposely documented to discuss the following quality measurements: percentage of residents who Self-report moderate to severe pain during a short stay, the percentage of residents who lose too much weight during a long stay, and percentage of residents with pressure ulcers that are new or worsened during the short stay.

The first quality indicator for this discussion is the percentage of residents who Self-report moderate to severe pain during their short stay in the hospital. According to CMS. gov (2015), the percentage of residents who Self-report moderate to severe pain during their short stay in the hospital refers to the percent of patients who stay for a short period of the healthcare organization with at least an episode of moderate or severe pain in the last five days. The numerical formula for obtaining this rate has both numerator and denominator. The numerator includes short-stay residents meeting either one or both of the following inclusion criteria. The first criterion establishes that the resident must report daily pain with at least an episode of moderate to severe pain. The pain must be almost constant, and there should be an episode of moderate to severe pain. The second criterion is that the residents should report very severe pain within any frequency limits. On the other hand, the denominator contains all hospitalized residents with selected target assessment. However, residents with exclusions such as in the case of incomplete pain interviews are not included in the denominator.

The data on this quality measurement are collected from the healthcare organization where the residents receive care during health inspection surveys. For example, nursing homes collect data on the residents routinely at intervals during their hospitalization. Health inspection survey findings are then updating in the CMS database for future retrievals. However, the self-reported data on the total residents might be manipulated, and this calls for ethical standards during data collection for a rating of nursing homes. Suchy (2010) posits that the ethical principles guiding public reporting are privacy and confidentiality, collaboration, accountability, transparency, legitimacy, informed understanding, data integrity, and continuous improvement. The data on the self-reporting of pain are extracted from the patient registers recording the daily activities and observations that the nurses record during duty. Joshi, Ransom, Nash, & Ransom (2014) opine that observational studies and statistical tools can be used effectively to find the causals of given phenomenon.

The quality measurement can be compared to other healthcare organization based on the rate of occurrence of the self-reporting. Consequently, hospitals with high rates of self-reporting will have a lower quality of care than hospitals with low incidences of self-reporting of moderate to severe pain. According to the2011 report availed by CMS. gov. (2015), the percentage of residents who Self-report moderate to severe pain during short stay has the second lowest rate of incidence among all the quality indicators with a difference between the 75^th and 25^th percentile of 17.2. The actual average rate of this quality measure is currently at 13.0%. A healthcare organization with high percentile and the low actual rate has a good quality of care and would have the highest rank. According to the CMS. gov. (2015), the only risk-adjusted values are for the long-stay pain measure, catheter, and short-stay pressure ulcers. Therefore, the short-stay pain measure of quality is not risk-adjusted. Goals can be set for this quality measure to ensure patients receive quality and safe care. The goals that can be set to reduce the percentage of residents self-reporting moderate to severe pain during short-stay include: to conduct a risk assessment for chronic pain, to manage pain effectively, and to ensure patients are regularly checked after 3-4hours to identify and alleviate factors contributing to pain. Poor pain management compromises patient safety because of the risk for secondary bacterial infections at the sites where the pain emanates and also psychological disturbance, and this makes life meaningless to patients. Also, the cost of managing advancing pain increases the overall cost of healthcare as the residents might even have their length of stay increased.

The next measure of quality is the percentage of residents who lose too much wait during a long stay. Poor quality of care can immensely contribute to loss of weighing during hospitalization. This measure refers to the percentage of residents in the long-stay program with a 5% or more weight loss in the last month or 10% and above in the previous two-quarters and was not on a prescribed regimen for weight loss. The numerator for this variable contains long-stay residents with a weight loss of 5% and above in the last month or 10% and above in the previous six months and was not on a weight-losing prescription. On the other hand, the denominator includes all the residents in the long-stay programs with a selected target assessment. This denominator does not include exclusions such as when the weight loss item is missing. The data for the numerator and denominator are collected from nursing homes. The number of long-stay residents is extracted from patient registers while the number of residents that lose weight as described above can be obtained from clinic notes and patient records made during daily check-ups.

These measurements must be compared to other healthcare organizations so that meaning can be derived from them. Such an analysis is also important in rating healthcare providers regarding the quality and safety of the care they provide. The percentage of residents who lose too much weight during long stay can be compared in terms of the actual rate and the percentile. According to the report compiled by CMS. gov (2015), the 90^th percentile was 13.0 while the actual number of the incidences of weight loss was at 13 761. The organizations with high incidences of weight loss have a low quality of care. This measurement is not risk-adjusted and therefore, its covariates are not applicable. Lastly, organizations can set goals to ensure their hospitalized residents do not lose weight under abnormal circumstances. These goals can include; providing adequate and balanced diet, to assess and treat diarrheal diseases promptly, and to provide emotional and social support to alleviate weight loss related to emotional stress. Loss of weight is associated with other factors such as low immunity, susceptibility to infections, fatigue, and low propensity to perform daily activities of living. Therefore, the quality of life of the residents will be low. Patients who loss remarkably amount of weight are also at risk of developing severe health conditions such as comatose due to hypoglycemia that leads to their admission to acute care centers. The cost of care in such acute settings is usually high due to the specialized care was given. Lastly, nursing homes are at risk for legal pursuits from patients when health conditions of patients worsened due to their poor care. As a result, nursing homes waste more time and money in such cases. According to Wachter & Pronovost (2009), the costs of lack of safety are severe such as the 4000 wrong-side surgeries done annually in the United States. Therefore, healthcare organizations must ensure they inculcate safety and accountability in their culture. 

The last quality measure for the discussion is the percentage of residents with pressure ulcers that are new or worsened during the short stay. This measure includes the percentage of residents in the short-stay program with observable new or aggravated stage two-four pressure ulcers.  CMS. gov. (2015) describes short-stay as the period with a CDIF less than or equal to a hundred days as of the end of the target duration. The numerical value in the formula for calculating this percentage contains residents in the short-stay session for which there was an indication of one or more new or aggravating stage two-four pressure ulcers when a look-back scan was used. On the other hand, the denominator includes all the residents with a single assessment or more that are suitable for a look-back scan. Nursing home residents are excluded from the equation if there is no assessment in the look-back scan responds to the stages of pressure ulcers mentioned above. The data for this quality measure can be collected by observation and recording of the exact number of patients who develop new bedsores or who exhibit worsening of the previous pressure ulcers. The number of residents for inclusion in the denominator can be obtained from secondary sources such as the patient registers and health records.

Comparisons can be made between healthcare providers using the actual rate and percentile ranking based on this quality measure. It is significant to note that a nursing home with a higher percentile and actual low rate of occurrence of this indicator of quality exhibits a high quality of care. According to the report compilation by CMS. gov (2015), the actual number of this indicator is at 10 763 while its 90^th percentile is at 4.9. High incidences of pressure ulcers mean that the quality of care in terms of regular ulcer risk assessment, repositioning of patients, and the facilities like bedding used by the resident is of very poor. This quality measure is risk-adjusted to limit inappropriate variations in score between healthcare providers. The risk adjustment uses covariates such as more or limited assistance in mobility self-performance in bed, occasional bowel assistance, low BMI, and peripheral vascular disease or diabetes. Therefore, the assessment is conducted only on patients with same risks of developing the morbidity to avoid external variations. An aggressive health care organization can set goals such as, to regularly reposition patients, to conduct assisted patient bed mobility, and to perform regular pressure ulcer risk assessments so that they limit the risk of developing bedsores. However, all the healthcare professionals within the organization must be involved in the goal setting for the goals to be achieved effectively. Lastly, bedsores can lead to other infections because the protective skin barrier is breached. Consequently, bacteria and other skin flora can penetrate to the blood and cause bacteremia. As a result, patients will incur additional cost for treatment of bedsores developed or worsened due to low-quality care.

Each of the quality measures aforementioned is important to the Rockville Nursing Home in Maryland. According to the U. S. News & World Report (2016), the percentage of residents who Self-report moderate to severe pain during short stay, percentage of residents who lose too much weight during long stay, and percentage of residents with pressure ulcers that are new or worsened during short stay are 7.6%, 1.7%, and 0.0% respectively. These measurements indicate that the nursing home is doing very well in terms of patient care and safety. However, the rate of self-reporting of moderate to severe pain is slightly high and therefore, the nursing home should develop strategies for ensuring adequate pain management. Weight loss among long-stay residents is also low, and this means the nursing home has the good nutritional program for the hospitalized patients. The zero rating of the prevalence of pressure ulcers during short-stay also indicates that the patients are cared for with adequate and quality bedding facilities. These rates have been availed to the public, and the nursing home is motivated to work to improve the quality of its services starting with the lowly rated measures. Park, Konetzka, & Werner (2011) posit that healthcare providers are improving their performance upon public reporting may benefit from their investment in the improvement of quality and safety of healthcare. Therefore, the nursing home will benefit financially from improving the quality of its services. These measurements are important as they can enable the organization to get Medicare intervention to perfect further the quality of the services it provides. The financial benefits are also likely to come from other organizations promoting quality improvement. According to CMS. gov (2015), CMS awards points to nursing homes based on their performance on the measures on each domain and these points adds up to the final score in ranking the organization. Therefore, these quality measures are also important for the nursing home to get a better ranking by the CMS.

In conclusion, quality measurement is important to determine the performance of a nursing home with regards to other healthcare providers. The three quality measurements described above are important for Rockville Nursing Home to determine the quality and safety of care it provides. Therefore, it should develop strategies to ensure it reduces these measures to achieve its goal of ensuring a healthy community.