Composite Measure Score

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

Webinar 'Using Composite Measure Score to drive quality and performance'


  1. Identify how to effectively assess and use the composite measure score and data to target measures for improvement
  2. Establish the Composite Measure Score tool as an identified resource to enhance quality improvement efforts


The composite measure score is a significant tool for monitoring improvement progress and outcomes. The composite measure score is comprised of 13, publically reported, long-stay quality measures that represent larger systems within the long term care setting. The composite score is calculated by summing numerators and denominators across all 13 quality measures to determine the composite numerator and denominator. Facility-level quality measure numerators, denominators, and rates are derived from the MDS 3.0. The composite numerator is then divided by the composite denominator and multiplied by 100 to obtain the composite score. Before the numerators and denominators can be summed, the direction of the two vaccine measures must be reversed because they are directionally opposite of the others. This is done by subtracting the vaccine numerator from the vaccine denominator to obtain a “reversed” numerator. The “reversed” numerator is counted in the composite numerator. By keeping all measure directions consistent, the composite score can be interpreted as the lower, the better.


 Next Steps

Review the Composite Measure Score; assess the quality measure(s) that are contributing to a heightened composite measure score; initiate improvement practices targeted to the measures that stand out as in need of focused attention; monitor ongoing progress with reducing composite measure rates.


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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