How to Create Composite Score Awareness Within Facilities
Jennifer Brown, Corporate QAPI Coordinator from Harber-Laman Management, Tenn., recently shared best practices with the atom Alliance nursing home collaborative for creating awareness around composite score goals, sharing the purpose of composite score data reports and using composite score data to create improvement.
As the lead for the atom Alliance nursing home team, I encourage you to use these best practices as a guide for making improvements in your own facility.
Creating Awareness
To begin creating awareness about the composite score, Brown:
- Educated facilities on the national composite score goal of 6.00 or less and what it meant
- Reviewed facility-specific trend reports from atom Alliance
- Distributed the Composite Score FAQs sheet to help understand what a composite measure was, where the data came from, how the composite score was calculated, the overall goals and more.
Determining Current Score
After looking at facility-level composite score quarterly reports from atom Alliance, the facilities:
- Prioritized their missed opportunities and started their process improvement efforts
- Pulled their own current data for the 13-long stay indicators from Casper QI/QM reports
- Used instructions from the Composite Score FAQs to manually calculate their composite score
Using Composite Score Reports
Composite Score reports helped the facilities:
- Monitor whether they were improving or missing opportunities in certain areas
- Set priorities on starting quality improvement projects
Making Improvements
Using the Composite Score reports, the facilities:
- Discovered there were issues of which they weren’t fully aware
- Created performance improvement projects (PIPs) to improve in certain areas
- Worked first on the higher numbers with the most missed opportunities
- Determined the root cause of each issue
- Used their QM task report (Casper Report Resident-Level Data Summary) to perform a detailed investigation of each resident that was flagged
- Put together a PIP team to analyze data, set goals, determine meeting schedules and summarize RCA findings
- Documented measures, including target date goal, benchmarks and how to capture measures
According to Brown, “It’s working well for us,” and now they are using a composite score calculator to help them continue to monitor their score, rather than determine it manually.
I invite you to learn more about how atom Alliance partners with nursing homes across five states to improve the quality of care for residents. Our quality improvement advisors are ready to work with you.
