Harmony Healthcare Blog

Quality Measure Improvement in Function: Top Two Questions about the Measure

Posted by The Harmony Team on Thu, Sep 08, 2016


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

Rehab.jpgThe new CMS Short Stay Quality Measure titled “Percentage of Short-Stay Residents Who Made Improvements in Function” was posted to Nursing Home Compare April 2016. Effective August 2016, this Quality Measure is integrated into the Five Star Rating System.

Currently, this measure will only be assigned half of its assigned point value (up to 50 Points of 1350) but will impact fully (100 points of 1600) in January 2017.  Many providers noted that although they have a strong rehabilitation program with obvious improvements (as evidenced by successful discharges home), the data shows they may have performed poorer than expected.  

The technical name for this measure is “Percent of Residents Who Improved Performance on Transfer, Locomotion, and Walking in the Corridor” (when referencing the recently updated MDS 3.0 CMS Quality Measure Manual released March of 2016).

The first question that Harmony Healthcare International (HHI) prompts the team to ask is:

“What MDS Assessments are utilized in the calculation of this important short stay Quality Measure?”

The answer is: A valid 5 Day MDS Assessment or Admission MDS Assessment is compared to the OBRA Discharge MDS Assessment for that episodes of care.


  • There must be a valid 5 Day Assessment or Admission MDS Assessment that precedes an OBRA Discharge MDS Assessment. (If the 5 Day or Admission MDS is combined with the Discharge MDS then it is not utilized in the calculation because it does not precede the Discharge Assessment).
  • If there is both a 5 Day and Admission MDS Assessment, the earliest assessment is compared.
  • The OBRA Discharge MDS with the closest date to preceding 5 Day or Admission MDS Assessment is used in this comparison.
  • The OBRA Discharge MDS Assessment must be coded as “return is not anticipated” (MDS Section A0310F = 10).
  • The OBRA Discharge MDS Assessment must be coded as “planned” (MDS Item A0310G).

MDS 3.0 RAI ManualThis measure does have exclusions, so any of the following items coded on the 5 Day MDS Assessment or Admission MDS Assessment utilized in this calculation will exclude that episode of care from the calculation. 

  • Comatose
  • Life expectancy of less than 6 months
  • Hospice

The second question that Harmony Healthcare International (HHI) prompts the team to ask is:

“What MDS Items are utilized to make the comparison and depict improvement which defines performance?”

The answer is: Performance is calculated by assigning points based on the coding of Self Performance as recorded on the MDS.  Independence (0), Supervision (1), Limited (2), Extensive (3) or Dependent (4).

If Self Performance is recorded as a 7 (activity occurred only once or twice) or 8 (activity did not occur) it is assigned a 4 points as if it were coded as Total Dependence.

Note that the support number of assist (1 or 2) is not utilized in the calculation.

The following MDS items are assigned points based on above:

  • Transfer
  • Locomotion on Unit
  • Walk in the Corridor

The sum of these items, as recorded on the 5 Day or Admission MDS Assessment, is compared to the sum of the of these items on the OBRA Discharge MDS Assessment


MDS Item

5 Day or Admission MDS

OBRA Discharge MDS










Locomotion on Unit





Walk in the Corridor





Total Points




If the sum on the OBRA Discharge MDS is less than the sum of the 5 Day (or Admission) MDS Assessment, then it is counted as Improved and positively impacts this Quality Measure.

  • Review the MDS Coding criteria for Locomotion on Unit and Walk in the Corridor (How does your facility obtain documentation for these items?)
  • Heightened focus on ADL coding accuracy on the OBRA Discharge MDS (Has the ADL accuracy focus been on PPS MDSs?)
  • Only code Independence for ADLs when it occurs for every occurrence in the 7 day look back period (Review the RAI Manual coding instructions when Independent and assist is provided less than 3 times at one level).
  • Only code “did not occur” for ADLs when there were no occurrences in the 7 day look back period (Did transfers or ambulation in the corridor only occur with Rehabilitation?)
  • Identify and code exclusion items when documented in the medical record (How does the MDS Department know a patient transferred to Hospice?)
  • Utilize the entire medical record to accurately code ADL items per the RAI Manual criteria.

Harmony Healthcare international (HHI) highly recommends interdisciplinary review, focused medical record review and Quality Measure Improvement in Function process evaluation when the improvement criteria do not reflect the patient’s actual performance.  

Harmony Healthcare International (HHI) is available to provide onsite analysis and associated medical record reviews to help you improve your Quality Measure Scores.  Please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413.  

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Topics: Quality Measures, MDS Short Stay, Improvement in Function

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