Malnutrition Care Score for IQR

The Malnutrition Care Score quality measure is available for reporting in the CMS Inpatient Quality Reporting Program.

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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.

MQii Toolkit / Plan for Data Collection

Section Takeaways

Following your completion of this section, you will know how to:

  • Identify indicators or metrics to track the impact of your improvement activities
  • Evaluate and prepare sources for data capture

Consider Opportunities to Track Improvement

Throughout your project, you will want to assess the effectiveness of your quality improvement activities. Tracking your results on the Malnutrition Care Score (MCS) eCQM is an ideal way to evaluate your progress toward your malnutrition care goals.  You will also want to track other progress indicators specific to your improvement project and the gap you identified.  For example, if you identified that malnutrition screening was less likely to occur when patients were admitted on weekends or directly to the ICU, you should track screening rates by day of the week and/or by admitting unit. The Project Champion / Lead and IT Developer / Report Analyst should identify quality measures and/or indicators that best align with your project objectives, fit the needs of your organization and Project Team, and capture changes to the clinical workflow.

Determine a Data Capture Mechanism

To inform your selection of progress indicators, you will want to consider the method you will use for collecting data. A consistent method of data collection should be used before, during, and post-implementation period for your quality improvement activities. Data collected during and following implementation will be used for comparison against any baseline data (collected prior to implementation) and help determine whether the change you implemented was carried out effectively and if it impacted your outcomes of interest.

We recommend using a hospital’s electronic health record (EHR) system when possible. The EHR typically allows for quicker and lower cost data abstraction compared with paper-based methods. As this varies by EHR, work with your IT Developer / Report Analyst to explore what data your system has available to collect related to your initiative and your ability to run custom reports. You may determine that you need to revise the way that nutrition data is captured in your EHR to enable more structured capture information. While this may require additional work in the beginning, most facilities find this initial work helpful to support easier implementation and data analysis during and following implementation.

Select Quality Indicators to Measure Success

Depending on the improvement activities you have selected to implement in your hospital, you may choose to use components of the Malnutrition Care Score, either as-is or customized to specific populations, units, times, or days of the week relevant to your improvement focus.  We also have a list below of ideas for quality indicators to track progress and outcomes. Collecting data on these indicators can be used to assess where you may have existing care gaps, track progress against quality improvement activities over time, and evaluate the impact of improved malnutrition care on hospital and patient outcomes.

If your EHR has built-in reports and analysis capabilities for the MCS, work with your IT Developer / Report Analyst to ensure that the right team members have access to those reports and understand how to use them.

In addition to the MCS, you should collect data on other indicators that meet your specific quality improvement goal(s). Quality measures or indicators should be identified prior to implementation of the selected improvement activity, along with the mechanism for their data capture, and communicated to the care team.

Suggested Quality Indicators

Clinical Workflow Stage:

  1. % of patients admitted to hospital who received a malnutrition screening with a validated screening tool
  2. % of patients admitted to hospital who received a malnutrition screening
  3. % of patients identified as “at risk” through a malnutrition screening who had a malnutrition-risk diet order
  4. Length of time between hospital admission and completion of malnutrition screening
  5. Length of time between identification of a patient as “at risk” based on a malnutrition screening and implementation of a malnutrition-risk diet order, but before a nutrition assessment
  6. Length of time between admission and implementation of a malnutrition-risk diet order in patients identified as “at risk” based on a malnutrition screening, but before a nutrition assessment
  1. % of patients identified as “at risk” based on a malnutrition screening who also had a completed nutrition assessment
  2. Length of time between patients identified as “at risk” based on a malnutrition screening and completion of a nutrition assessment
  3. Length of time between admission and completion of a nutrition assessment for patients identified as “at risk” based on a malnutrition screening
  1. % of patients identified as malnourished with a nutrition assessment who have a documented dietitian-based malnutrition diagnosis
  2. % of patients identified as malnourished by a dietitian who have a documented medical provider diagnosis of malnutrition
  3. % of patients identified as malnourished who have both a dietician-documented and a medical provider-documented diagnosis of malnutrition
  1. % of patients with a completed nutrition assessment and a documented malnutrition diagnosis who have a documented malnutrition care plan
  1. % of patients with a documented malnutrition diagnosis who had a nutrition intervention implemented
  2. Length of time between documented malnutrition diagnosis and implementation of a nutrition intervention for patients diagnosed as malnourished
  3. Length of time between admission and implementation of a nutrition intervention for patients diagnosed as malnourished
  1. % of patients with a malnutrition diagnosis who have a malnutrition care plan included as part of their post-discharge care plan

For any quality indicator you track, it’s important to analyze the data to understand key drivers of the results. Ways in which you may want to consider breaking down your data include:

  • Age ranges (18-64, 65+, etc.)
  • Admitting unit
  • Admitting diagnosis / clinical condition
  • Day of the week (e.g., weekends vs. weekdays)
  • Time of day (e.g., day shift vs. night shift)
  • Emergent vs. elective admission
  • Patient cognitive status
  • Admitting or attending service (e.g., trauma, oncology, etc.)

Other quality indicators that your organization should consider tracking are listed below. These concepts assess aspects of patient-centered care and high-priority clinical outcomes that may be affected by your project implementation.

Suggested Patient-Centered Quality Indicators

  • Consideration of patient preference in initiating a malnutrition-risk diet order
  • Confirmation of malnutrition screening by the patient at discharge
  • Confirmation of receipt of malnutrition education by patient and/or family caregiver at discharge
  • Consideration of patient or family preference initiating a feeding tube during end-of-life care

In addition to these quality indicators, you should also consider tracking impact on hospital- and patient outcomes, such as readmissions and length of stay, looking at year-over-year comparisons as well as continuous tracking pre-, during, and post-implementation of your improvement initiative.  You can find additional information on malnutrition’s impact on these outcomes in this article from the American Society for Parenteral and Enteral Nutrition (ASPEN) and the Academy of Nutrition and Dietetics.

  • Length of Stay
  • Readmissions Rates
  • Pressure Ulcer Rates (hospital-acquired)
  • Infection Rates (hospital-acquired)
Last Updated on October 27, 2026

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