1. After you open the Composite Calculator spreadsheet and before you begin working in it, click the "Enable Content" button when the Macro Security Warning appears.

2. Obtain your quality measure data by downloading your CASPER "MDS 3.0 Facility Level Quality Measure Report" for the current reporting period. This report is a six month running average of a nursing home's quality measures. The current period will default to the last day of the previous month and begin on the first day of the month that began six months prior. Additionally, the Comparison Group will be a different six month reporting period because of the time lag it takes CMS to compile national and state date to create the comparison group.

NOTE: If you do not know how to obtain your CASPER report, speak to your MDS coordinator or the

3. Enter the numerators from your current CASPER report for the 11 long-stay measures highlighted in the graphic below into the "Current Numerator" column of the Composite Calculator.Note: The 11 long-stay quality measures used are:

1. Moderate to Severe Pain

2. High-risk Pressure Ulcers

2. High-risk Pressure Ulcers3. The use of Physical Restraints4. Falls with major injury5. Antipsychotic medication use6. Depression7. UTIs8. Catheter inserted or left in the bladder9. Low risk bowl and bladder continence

10. Excessive weight loss11. Increased ADL assistance

4. Enter the denominators from your current CASPER report for the 11 long-stay measures highlighted in the graphic below into the "Denominator" column of the Composite Calculator.

Note: The 11 long-stay quality measures used are:1. Moderate to Severe Pain

2. High-risk Pressure Ulcers3. The use of Physical Restraints4. Falls with major injury5. Antipsychotic medication use6. Depression7. UTIs8. Catheter inserted or left in the bladder9. Low risk bowl and bladder continence

10. Excessive weight loss11. Increased ADL assistance

7. Next, after the composite score is determined use the predictive functions of the spreadsheet to set quality measure reductions goals. To populate the "Desired Numerator Goal", click the Populate Desired Numerator Button and the data from the "Current Numerator" column will populate in the

6. Once all the needed numerators and denominators are entered into the Composite Calculator, your composite score will autocalculate. The composite score will automatically highlight in red, yellow, or green based on the size of the composite score.

a) RED - 7.01 or higherb) YELLOW - between 6.01 and 7.00c) GREEN - 6.00 and below

5. The Influenza and Pneumococcal vaccination rates are also needed to calculate your composite score. You can obtain this information from the Quality Improvement Organization in your state. Once you have your numerators and denominators for both vaccine categories, enter them into their respective cells in the spreadsheet.

Desired Numerator Button and the data from the "Current Numerator" column will populate in the

8. Determine the goals you would like to set for individual quality measures. Once you have some goals in mind, change the value in the "Desired Goal Numerator" column to represent a decrease in value of the particular quality measure. Once the values for individual quality measures have been changed, the composite score will be recalculated to represent the overall decrease. There is also a box on the right of the Composite Calculator that will help determine the total decrease the numerator must reach to result in a composite score of 6.00 or less.

NOTE: In the example below the quality measure categories highlighted and with blue arrows next to them have been decreased to represent overall project goals. Additionally, if these changes are made then the composite score will decrease to 6.78. Lastly, a further reduction of the desired numerator

9. Once the analysis is complete, save the spreadsheet by utilizing the SAVE AS function and rename the worksheet.

10. After the spreadsheet has been saved with a different name, all current numerators and denominators can be cleared by pushing the "Clear Composite Calculator" button. The desired goal numerators will remain for future goal tracking purchases.

spreadsheet and before you begin working in it, click the

"MDS 3.0 Facility Level Quality Measure Report" for the current reporting period. This report is a six month running average of a nursing home's quality measures. The current period will default to the last day of the previous month and begin on the first day of the month that began six months prior. Additionally, the Comparison Group will be a different six month reporting period because of the time lag it takes CMS to compile

NOTE: If you do not know how to obtain your CASPER report, speak to your MDS coordinator or the

stay measures highlighted in

stay measures highlighted

after the composite score is determined use the predictive functions of the spreadsheet to set quality measure reductions goals. To populate the "Desired Numerator Goal", click the Populate Desired Numerator Button and the data from the "Current Numerator" column will populate in the

needed numerators and denominators are entered into the Composite Calculator, your composite score will autocalculate. The composite score will automatically highlight in red, yellow, or

rates are also needed to calculate your composite score. You can obtain this information from the Quality Improvement Organization in your state. Once you have your numerators and denominators for both vaccine categories, enter them into their

Desired Numerator Button and the data from the "Current Numerator" column will populate in the

you would like to set for individual quality measures. Once you have some goals in mind, change the value in the "Desired Goal Numerator" column to represent a decrease in value of the particular quality measure. Once the values for individual quality measures have been changed, the composite score will be recalculated to represent the overall decrease. There is also a box on the right

the numerator must reach to

NOTE: In the example below the quality measure categories highlighted and with blue arrows next to them have been decreased to represent overall project goals. Additionally, if these changes are made then the composite score will decrease to 6.78. Lastly, a further reduction of the desired numerator

function and rename

denominators can be cleared by pushing the "Clear Composite Calculator" button. The desired goal