QISInformation to Support States

Preparing for QIS Training and Implementation

1

Agenda

Welcome and Introductions Background and Overview of QIS QIS – Continuous Quality Improvement State Roles and Responsibilities in

Training Process Description and Timing of QIS Training Questions

2

3

What is the QIS?

Approved Federal nursing home survey process to increase consistency, reliability and accuracy

Uses customized software on tablet PCs to guide surveyors through a two-staged systematic review of the regulatory requirements

4

QIS Development

Produce prototype (1998 – 2005)

Demonstration and Evaluation (2005 – 2007)

– Two teams each in: KS, OH, CA, CT, LA Develop and refine national training model (2006

2007)

– Three States: FL, CT, KS Three States: FL, CT, KS National implementation State-by-State to replace

Traditional survey (2007 – present)

What Does the QIS Provide?

Structured approach to achieve more accurate and consistent results

Larger and more diverse randomly selected samples to obtain a more accurate picture of the residents

Automation to systematically review regulatory areas, synthesize surveyor findings, enhance investigative protocols, and organize surveyor documentation

5

What QIS Is Not

QIS Does Not Represent:

Change in Social Security Act

Change in the Regulations

Change in Interpretive Guidance

Change in enforcement process

6

Comparison of QIS and Traditional Survey Process

7

Automation

Traditional

Information recorded on paper throughout process; computers are used for Statement of Deficiencies (CMS-2567)

QIS

Each team member uses a tablet PC to document findings throughout the process; findings are synthesized, organized, and loaded to the CMS-2567 by the software

8

Offsite Preparation

Traditional Review:

OSCAR 3 and 4 Reports

QM/QI ReportsResults of

complaint investigations

Pre-select a sample based on above

QIS Review:

OSCAR 3 ReportUninvestigated

complaints Random selection of

Stage 1 samples from MDS data loaded onto tablet PCs

9

Onsite Preparation

Traditional Roster/Sample Matrix –

Form CMS-802

QIS Alphabetical resident

census with room numbers/units

List of new admissions over last 30 days

10

Initial Tour

Traditional Gather information

about pre-selected residents and identify new concerns

Determine whether pre-selected residents are still appropriate

QIS Brief overall

impression of the facility, the residents, and the staff

Not intended for sample selection or supplementation

11

Sample Selection

Traditional Sample size determined

by facility census Residents selected

based on QM/QI percentiles and issues identified offsite and on the initial tour

QIS Stage 1 sample size:

Admission (30)

Census (40) Stage 2 sample size

based on number of triggered care areas

Residents selected by software

Surveyor-initiated sample

12

Survey Structure

Traditional Phase I: focused

& comprehensive reviews

Phase II: focused reviews

QIS Stage 1:

preliminary investigation

Stage 2: in-depth investigation of triggered concerns from Stage 1

13

14

Two Stages of QIS

Stage 1: Preliminary investigation of regulatory areas to determine resident care areas and facility practices for Stage 2 investigation

Stage 2: In-depth investigation to determine whether deficient practice exists, document deficiencies, and determine severity and scope

15

Three Steps in Each Stage

1. Sampling (computer-generated)

2. Investigation

3. Synthesis

16

QIS Stage 1

Sampling – Random census (40) and admission (30) samples

Investigation – Structured resident, family, and staff interviews; resident observations; chart reviews

Synthesis – 128 resident-centered and 34 facility-level Quality of Care and Quality of Life Indicators (QCLIs) to identify care areas that exceed national thresholds

17

Stage 1 Triggers for Stage 2 Investigations

18

Surveyor-Initiated Sample

Surveyors can initiate an investigation of care areas for any resident or of facility tasks. Because of the large QIS samples, surveyor-initiated investigations are a small part of the process.

19

QIS Facility Tasks

Completed on every survey– Liability Notices & Beneficiary Appeal Rights Review – Dining Observations– Infection Control and Immunizations– Kitchen/Food Services– Medication Administration and Drug Storage– QAA– Resident Council President Interview

Completed if triggered – Abuse Prohibition Review– Admission, Transfer, and Discharge Review– Environmental Observations– Personal Funds Review– Sufficient Nursing Staff Review

20

QIS Stage 2

Sampling – Three residents per triggered Care Area plus surveyor-initiated residents (e.g., complaints)

Investigation – Specific or general Critical Element pathway or facility task pathway and interpretive guidelines

Synthesis – Determine compliance with each Critical Element, document noncompliance at the applicable F tags, determine severity and scope

QIS Satellite Broadcast: http://surveyortraining.cms.hhs.gov/pubs/VideoInformation.aspx?cid=1082

QIS Resource Manual:

http://www.uchsc.edu/hcpr/qis_manual.phpQIS Electronic Forms and Worksheets:

http://www.uchsc.edu/hcpr/qis_forms.php QIS Brochure:

http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter08-21.pdf

2121

Additional Information

QIS – Quality Improvement

CMS-Federal Monitoring of the QIS RO surveyors trained in QIS process Desk Audit Reports

DAR-SA for State DAR-RO for CMS Regional Office

Federal Oversight of the QIS (FOQIS) QIS Comparative Survey

22

23

QIS - Quality Improvement

Desk Audit Report (DAR)a management tool which can be used by: The CMS CO for ongoing monitoring of

QIS consistency across Regions Offices (RO) and States (SA);

The RO’s for Federal Oversight of the QIS process (FOQIS); and

The SA’s for monitoring districts, teams and individual surveyors

RO & SA use of the DAR

Reviews results; Raises questions; Investigates outcomes; Assists the RO & SA with

oversight/training; and Can direct SA monitoring

24

25

Timeline

CU sends 6 DAR-SAs with clinical analysis and a call to discuss each

CU sends 3 DAR-SAs with clinical analysis and no call

SA receives clinical analysis training CU and SA comparison for one DAR-SA SA assumes responsibility of analyzing

DAR-SAs

Goal of QIS Data

Identify and address sources of inconsistency: Implementing the QIS process

accurately

Conducting adequate and thorough investigations and making accurate compliance decisions

26

DAR-SA Review

1. Throughout each quarter, SA reviews multiple DAR-SAs

– Identify and analyze outliers/trends

– Determine root cause

– Implement training, monitoring or corrective action as appropriate

– Monitor effectiveness

27

DAR-RO Review

2. At the end of the quarter, RO and SA receives State-Specific DAR-RO

3. RO conducts QI call within 4 weeks (not fully implemented)

4. Onsite FOQIS is conducted using a targeted, data-driven approach (not fully implemented)

28

Preparing for Successful QIS Training and Implementation

Review CMS Issued Documents Fiscal Year State Survey & Certification Budget Letter (Mandatory

Requirements - equipment and encryption) State Operations Manual, Appendix P QIS Training Process - State Operations Manual, Chapter 4 National Implementation Priority Order (S&C 09-50) QIS Satellite Broadcast:

http://surveyortraining.cms.hhs.gov/pubs/VideoInformation.aspx?cid=1082 QIS Brochure:

http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter08-21.pdf

29

Preparing for Successful QIS Training and Implementation

Informing State management about QIS

Identifying QIS management and teams

Educating stakeholders in the State

Begin logistics preparation for initial QIS classroom training

30

Preparing State Management Team for QIS

Kick off call with State, CMS, and NHQ

Orient and educate managers/supervisors about QIS, the training process and

State develops QIS training plan

Identify a QIS State Lead

Identify a QIS IT Lead

Identify 8 surveyors to participate in initial/core QIS Classroom Training

Identify additional support staff to help with preparatory logistics for QIS training

31

Role of QIS State Lead

Able to make supervisory decisions and provide oversight Support the QIS process Participate in QIS training, classroom and field Achieve mastery of the QIS Manage potential challenges from nursing homes Serve as the point of contact for the State Agency for

discussion with CMS and/or its contractors Educate provider and consumer organizations Collaborate in the planning and preparatory activities with

the training contractor

32

Role of QIS State IT Lead

First line of contact for surveyors to address and resolve software issues using the QIS process and QIS software

Successfully completes ASPEN Technical Training Experienced and proficient with all ASPEN suite of products

Creating survey shells in ACO Assisting staff with uploading surveys from ASE to ACO

Participates in both classroom and onsite QIS training Able to train additional staff on the technical aspects of the

QIS process

33

QIS Core Group of Surveyors

State identifies eight surveyors (2 teams of 4) to participate in initial round (core) of QIS training Minimum of two years of recent LTC survey experience SMQT qualified Possess intermediate computer skills Prior teaching or training experience, if possible

State selects four QIS trainer candidates from initial core group of surveyors trained in QIS

34

Educating Stakeholders on QIS & State’s Implementation Plan

Dedicate a section of State Web site for QIS information and resources for stakeholders

Schedule, announce and participate in “Overview of QIS for Stakeholders” with CMS and NHQ

Communicate with stakeholders regarding the QIS process and the QIS implementation in the State on an ongoing basis

Stakeholder education is key to successfully implementing QIS

35

Preparatory Logistics and Tasks for Core Group QIS Training

QIS Classroom Logistics Checklist call with NHQ QIS IT Logistics Checklist call with NHQ Schedule 1-Day IT Training led by Alpine Technology Group

for State’s IT staff Secure all necessary equipment for QIS training Determine classroom location and nursing homes for mock

(simulated training)survey and surveys of record Load and test participant tablets PCs with QIS software/files State led computer orientation training for surveyors

participating in QIS training

*Please refer to the QIS Training Timeline document and QIS Classroom Logistics Checklist for a detailed list of logistics

36

QIS Classroom Training

37

Training Requirementsfor Registered QIS Surveyor

Prerequisites

Proficiency with tablet PC functions and computer skills

Completion of classroom training Participation in mock training survey Participation in surveys of record with successful

compliance assessment Documentation in CMS Learning Management System

(LMS)

39

Initial (Core) QIS TrainingExample

QIS Train-the-Trainer (T3)

40

Training Requirements for CMS-Certified QIS Trainer

Be Registered QIS Surveyor Successfully complete additional requirements

Complete at least six QIS surveys of recordAttend Train the Trainer workshopProvide the QIS classroom training Monitor surveyor-students in mock survey Conduct compliance assessment for surveyor-

students during a survey of record Remain actively involved in QIS training/surveys

Documentation in CMS Learning Management System (LMS)

42

QIS Train-the-Trainer (T3) Schedule Example

Tips for a Smooth QIS Training

Provide a comfortable classroom learning environment and furnish required equipment

Educate State management about QIS Supervisors participate in training Recognize the learning curve and additional time needed to

complete QIS (Plan on a minimum of 40 in-facility hours per surveyor per week)

To the degree possible, select facilities for the mock & surveys of record that do not have a history of serious care issues and consider commute time for surveyors

Avoid adding tasks such as licensure review to QIS surveys during initial QIS training activities

43