Working to improve the quality of care delivery to nursing home residents.

Webinar - Using CASPER data to drive performance

Objective - Identify how to collect, use, and share key data to drive quality and performance improvement.


Quality Measure & Reports

Understanding the Quality Measures; correlated reports, and the link to assessing quality care issues and quality improvement (QI) opportunities is essential to any improvement program. The Quality measure reports are key resources to help identify potential causal issues contributing to less than favorable improvement outcomes. The QM reports are used to search for correlation, to help understand the impact of a single click on the MDS; and as a work through in the quality improvement process.

How to find the facility QM reports

This depends on the MDS software used to submit MDS assessments. The CMS Health Care Quality Improvement System (QIES) system is accessible to all nursing homes. QIES is the key source of quality data for CMS; is a national system that supports the Survey & Certification program; and fulfills CMS’ quality initiatives for select provider settings.

Through the QIES system you will have access to the CASPER Quality Measure Report page and three important and useful reports:

  1. Facility Quality Measure Report
    The facility quality measure report features 17 quality measures that are stratified into short stay and long stay quality measures. Short stay versus long stay has to do with the cumulative, or total, days in the facility. It does not include any days when the resident was out of your facility, like hospital or at home. A short stay resident has total cumulative days in facility of 100 days or less. A long stay resident on the quality measure report has 101 days or more in your facility. These are mutually exclusive, which means on any given report, the resident is only in one category. They are either a short stay resident or a long stay resident. The report defaults to a specific date range/report period unless specified. Each measure is represented by a % or rate. The basic calculation is pretty simple. The numerator, or those residents with the problem (who trigger), divided by the denominator, all of those who could have had the problem. Times that by 100, and that gives you the percentage.
  2. Resident Level Quality Measure Report
    The report drills down information to the individual resident level. This report is useful for identifying all residents that triggered a problem or clinical issue within a specific date range. Individual residents and corresponding QM triggers are identified; the information is useful for identifying potential coding errors, correlation, and deciding strategies to prevent negative outcomes. I.E. a resident triggers the fall, antipsychotic medication, and behavior QMs. Analyzing the report; can a correlation be made that the fall occurred due to the effects of inappropriate anti-psychotic medication? Or did the behavior contribute to the fall? Use the report to analyze causal effect and build preventative programs.
  3. Facility Characteristics Report
    The snapshot report pinpoints the facility characteristics. The report notes how many men, how many women, age breakdown, how many residents are on hospice, how many residents have a psychiatric diagnosis etc. The information is an outline of the facility and may be useful to identify some quality improvement opportunities.

How to Use the QM report

To fully and effectively analyze a Quality Measure Report, it is important to link it with the information in the MDS 3.0 Quality Measure User’s Manual. Once you’ve selected a quality measure to improve, dig deeper and conduct a root cause analysis.  Look at the QM report; review the targeted measure’s specification (numerator, denominator, exclusions) and compare the information with the resident level report or residents that trigger the measure. With all information at hand develop an improvement methodology, measurement source, and timeline to monitor effectiveness and outcome.


CASPER (Certification And Survey Provider Enhanced Reports) is an operational data resource to monitor the status of the organizations short and long term quality measure rates and the effectiveness of applied improvement strategies. The data will require regular interpretation in order to achieve insightful reporting and action. CASPER Quality Measure Reports contain quality measure information at the organizational, state, and national level for a dedicated reporting period. The CASPER system offers varied reports; Organization and Resident Quality Measure Reports are available in the system including the numerator, denominator and reported percent values for each of the publicly reported MDS 3.0 quality measures, and also displays the list of residents who triggered one or more of the publicly reported MDS 3.0 Quality Measures.

Using CASPER data to drive performance (Video)

Casper Transcript


Casper Reporting MDS Provider User’s Guide

Next Steps 

Review the CASPER data and become familiar with the organizations individual reports. Decide what CASPER data to routinely monitor. Determine the method of collection and monitors for analysis and progress. Based on the data, set targets for improvement and decide on the factors (processes or outcomes) for changing or continuing quality strategies.


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Contact Us

New York

Pauline Kinney, RN, MA, LNHA, RAC-CT
Senior Director, Health Care Quality Improvement
Tel: (516) 209-5402
Fax: (516) 326-0434

Maureen Valvo, RN, BSN, RAC-CT
Senior Quality Improvement Specialist
Tel: (516) 209-5308

David L. Johnson, NHA, RAC-CT
Senior Quality Improvement Specialist
Tel: (518) 320-3516

Dan Yuricic, MA
Senior Quality Improvement Specialist
Tel: (516) 209-5458

IPRO Nursing Home Team