Quality Indicator Survey (QIS) Design and

Development

Martha Powell, PhDAssistant Research Professor

Division of Health Care Policy and Research

September 13, 2012

University of Colorado’s role in implementation and analysis of QIS

Development and Implementation of the QIS

Threshold development and review QIS in Indiana

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Presentation Overview

Software design and testing Stage 1 and Stage 2

revisions/improvements Desk Audit Reports Threshold analysis Help Desk Onsite support for SA/RO

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CU’s Role

Traditional Paper forms, prelim sample from QM/QI, tour

used to supplement sample, comp review then focused reviews

QIS Computer assisted (tablets), random samples,

wide variety of indicators, prelim invest then in-depth for selected areas

Both shaped by OBRA ‘87

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Survey Process

Pre-cursor to QIS (Quality Indicator Survey) developed to serve as standard to gauge effectiveness of survey process improvements

Development involved Univ. of Wisconsin, Univ. of Colorado, and programming contractors

Pilot Tests (field, alpha, beta), then Demonstration and Evaluation

National Implementation—phased approach

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History of QIS

Computer-assisted (tablets), 2 stages Stage 1: Preliminary Investigations

Random sampling Structured protocols

Stage 2: In-depth investigations Facility tasks (e.g., Kitchen, Infection Control &

Immunization Review) Surveyor Initiation option Typically four surveyors onsite for 5 days

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QIS Basics

Census Sample (N=40): Resident Interview/Observation Staff Interview Record Review Family Interview (n=3)

Admission Sample (N=30): recently-admitted residents Record Review

MDS Sample: assessments from prior 180 days

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Stage 1

Quality of Care and Quality of Life Indictors Examples of QCLIs: Underweight and No Supplements,

Eating Decline Since Admission, Hospitalization within 30 days of Admission

Computed from Stage 1 and MDS samples/data Facility rate is calculated and compared to pre-set threshold

If facility rate exceeds threshold, the care area (e.g., Nutrition, ADL, Hospitalization) is triggered for a Stage 2 investigation (e.g., 4 residents out of 40 have Stage III/IV pressure ulcers—10% facility rate—exceeds 5% threshold)

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QCLIs

Rates – threshold = 10% (example rate) For a census sample of 40, 10% would be 4 residents, so 5 would

be needed to exceed threshold For an admission sample of 30, 10% would be 3 residents, so 4

would be needed to exceed threshold Threshold for Abuse is 0—only 1 resident is needed to exceed

the threshold Not percentiles or benchmarks Reviewed and reset if appropriate Based on QIS data Separate threshold values for smaller census/admission

samplesUniversity of Colorado Anschutz Medical Campus 9

Thresholds

Survey QCLI Rate

Cited?

19%1 20% N2 20% N3 22% N4 35% N5 40% Y 6 41% N7 50% Y 8 70% Y

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Simplified QCLI Threshold Analysis

If current threshold is 19% 8 – TRIGGERED and 3 – CITED

3/8 or 37.5% citation rate

Survey QCLI Rate

Cited?

19%1 20% N2 20% N3 22% N4 35% N5 40% Y 6 41% N7 50% Y 8 70% Y

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Simplified QCLI Threshold Analysis

If current threshold is 37% 4 – TRIGGERED and 3 – CITED

3/4 or 75.0% citation rate

Survey QCLI Rate

Cited?

19%1 20% N2 20% N3 22% N4 35% N5 40% Y 6 41% N7 50% Y 8 70% Y

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Simplified QCLI Threshold Analysis

If current threshold is 45% 2 – TRIGGERED and 2 – CITED

2/2 or 100.0% citation rate

Census Sample Small: 35 or fewer residents Not Small: 36 – 40 residents

Admission Sample Small: 9 or fewer residents Not Small: 10 – 30 residents

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Small/Not Small Sample Thresholds

In-depth investigations of triggered care areas and non-mandatory facility tasks

Critical Element Pathways guide investigation

Additional interviews, observations, and record reviews

Compliance decision Is facility in compliance with regulations? Individual and then as team

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Stage 2

After SMQT Extensive Classroom training (computer

basics, QIS process and software) Mock survey—putting training into practice Compliance surveys—performance is

evaluated by QIS Trainers Additional classroom and onsite education to

become a QIS Trainer

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QIS Surveyor Training

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QIS Implementation

First surveys conducted in January, 2011 As of 7/17/2012—212 QIS ( 500 NH) 15 of 21 teams trained Full implementation can take up to 3 yrs.

Following slides/results are based upon QIS from 1/28/2011 – 7/17/2012; National and Indiana QIS results from same time period

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QIS in Indiana

National and Indiana rates are similar for the following: Frequently Triggered (> 60% of surveys)

Abuse/Abuse Prohibition, Accidents, ADLs, Community Discharge, Dental Status, Nutrition, Personal Property, Pressure Ulcers, Psychoactive Meds

Less Frequently Triggered (< 20% of surveys) Food Quality, Notification of Change, Privacy,

Sufficient Nursing Staff, Social ServicesUniversity of Colorado Anschutz Medical Campus 18

Triggered Care Areas

Indiana is a low outlier (compared to National QIS rates) for: Physical Restraints and Positioning

No high outliers for Indiana for triggered care areas

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Triggered Care Areas cont’d

Indiana QIS rates for: Resident Observation 5% Resident Interview 7% Family Interview 3% Staff Interview 10% Census Clinical Record 5% Admission Clinical Record 5%These rates are similar to Nat’l QIS rates.

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Source of “Negative” Responses

Liability Notices 25% (↑than Nat’l QIS) Dining 23% Infection Control 46% (↑than Nat’l QIS) Kitchen 27% QA & A 13% (↑than Nat’l QIS) Resident Council 13% (↑than Nat’l QIS) Med. Admin 13% Med Storage 22% Unnecessary Med Use 39%

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Citation Rates for Mandatory Facility Tasks

Abuse Prohibition 23% Adm, Tfr, DC 22% Environment 74% Personal Funds 26% Sufficient Nursing Staff 13% Extended Survey 60%Rates = # cited divided by # investigated (not total # of surveys)

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Citation Rates for Non-Mandatory Facility Tasks

Indiana QIS similar to Nat’l QIS for most

Indiana QIS low outlier for: Behavioral and Emotional Status,

Rehabilitation, UTIs Indiana QIS high outlier for:

Physical Restraints and PositioningUniversity of Colorado Anschutz Medical Campus 23

Citation Rates for Triggered CA/Tasks

Percentage of F-tags at each S/S level for Indiana QIS very similar to Nat’l QIS, slightly higher percentages at A & B

IN QIS Nat’l QISA 3.6% 1.2%B 4.8% 2.7%C 3.9% 3.0%D 64.3% 65.3%E 17.6% 19.9%F 3.2% 4.8%G 2.5% 2.4%H – L 0.2% 0.55%

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Scope and Severity

Nationally in QIS statesF441 Infection Control -- 34.9%F329 Drug Regimen free from Unecc. Drugs -- 34.1%F323 Free of Accident Hazards -- 31.3%

Indiana QISF282 Srvcs by Qualified Persons per Care Plan -- 44.7%F323 Free of Accident Hazards -- 41.6%F279 Develop Comp. Care Plans -- 41.1%

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Most Frequently Cited F-tags

Nat’l QIS IN QIS diffF282 21.1% 44.7% -23.6%(Svcs by Qual. Pers per CP)

F156 12.1% 28.9% -16.9%(Notice of Rights)

F253 19.5% 32.0% -12.5%(Housekeeping)

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Citation Rates for Selected F-tags

Nat’l QIS IN QIS diffF280 27.8% 22.3% 5.5%(Right to particp. In CP)

F281 9.9% 4.1% 5.8%(Srvcs. meet Professional Stds.)

F272 24.4% 17.8% 6.5%(Comprehensive Assessments)

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Citation Rates for Selected F-tags

Nat’l QIS IN QISF492 3.2% 0%(Comply w/Fed/St/Local Laws/Prof. Stds.)

F274 1.6% 0%(Comp. Assess. After Sig Change)

F497 1.2% 0%(Nurse Aide Perform Rev-12 hr/yr in-service)

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Citation Rates for Selected F-tags

Nat’l QIS IN QISAverage Number of

Citations per Survey 6.9 8.4

Percentage of Citation- Free Surveys 6.9% 9.6%

Survey Time (Prep, Onsite, Offsite) 139.3141.5

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Citations and Survey Time

University of Colorado QIS websitehttp://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/hcpr/qis/Pages/default.aspx

CMS Project OfficersSusan Joslin (Susan.Joslin@cms.hhs.gov)andTom Kress (Thomas.Kress@cms.hhs.gov)

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Contact Information

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Questions?Martha PowellMartha.Powell@ucdenver.edu (303) 724-2434

Sayuri KellySayuri.Kelly@ucdenver.edu(303) 724-2490

For CMS QIS forms and Information:https://www.qtso.com/qisdownload.html