Global Malnutrition Composite Score for IQR

The Global Malnutrition Composite Score quality measure is now available for 2024 hospital reporting.

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The Malnutrition Quality Improvement Initiative
The MQii is designed to help your organization improve
malnutrition care and subsequently achieve better outcomes.

Quick Start Guide

Quick Start Guide for Quality Improvement and Reporting on the Global Malnutrition Composite Score (GMCS) Measure

Reporting on the GMCS measure is a 2-step process. STEP 1 is implementing malnutrition quality improvement (QI). If your hospital is already implementing malnutrition QI, then jump to STEP 2 and prepare your electronic health record (EHR) for GMCS data collection, monitoring, and reporting.

STEP 1: Implementing malnutrition quality improvement (QI)

Malnutrition QI helps identify gaps and implement improvements in your hospital’s nutrition care process to support better patient and healthcare outcomes. The nutrition care process is the basis for the 4 components of GMCS:

  1. Connect with your hospital’s quality improvement department or manager to assess your hospital’s malnutrition care processes and compare to the standard nutrition care process workflow.
    1. Working with your hospital quality improvement department will help with workflow assessment and QI implementation.
  2. Identify and prioritize your top areas for malnutrition care process and documentation improvement.
    1. Example areas include improving the hospital malnutrition screening processes to identify patients at risk for malnutrition within 24 hours of admission or appropriate documentation of all malnutrition diagnoses in the electronic health record (EHR).
    2. The Project Prioritization Matrix can help your team determine the most critical focus areas to prioritize for malnutrition QI implementation.
  3. Create and implement a plan with your care team to address prioritized areas for malnutrition care process and documentation improvement.
    1. Using the QI Plan-Do-Study-Act (PDSA) process can help streamline QI implementation, check out these sample malnutrition PDSA templates.
    2. Regular communication with the care team and quality improvement department will help keep your QI plan on track. Note it may take several PDSA cycles to meet your quality improvement goals.

STEP 2: Preparing your EHR for GMCS measure data collection, monitoring, and reporting

  1. Connect with your hospital information technology (IT) department to ensure your EHR currently has (or can have) the capability to capture the necessary data elements for the GMCS.
    1. Documentation of the nutrition care process in the EHR is essential to evaluate quality improvement success and allow for reporting on the GMCS to CMS.
  2. Start early to ensure your IT request is prioritized, as integrating the GMCS components into the hospital EHR can take time.
    1. Review more specific resources about collecting data related to the GMCS to prepare for integration into the EHR.
  3. Work with your hospital quality improvement department or manager to plan for GMCS reporting.
    1. Hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program can report on the GMCS starting in 2024.
    2. Reporting on the GMCS will be voluntary in 2024. Continuing to keep your hospital quality improvement department or manager engaged in your malnutrition QI work and GMCS data collection and monitoring will help prioritize the opportunity for GMCS reporting. Use the PowerPoint presentation below to educate your colleagues about this important opportunity. 
GMCS Presentation Title Slide

Download and present these PowerPoint slides to your colleagues (e.g., hospital administrators, fellow clinicians) to share the GMCS reporting opportunity with them. For help determining which slides are recommended for which audience, see this version of the PowerPoint

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Last Updated on September 19, 2024

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The Malnutrition Quality Improvement Initiative

These materials were developed by the Malnutrition Quality Improvement Initiative (MQii),
a project of the Academy of Nutrition and Dietetics, Avalere, and other stakeholders who
provided guidance and expertise through a collaborative partnership. Support provided by Abbott.

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