Transcript Quality Indicator Survey (QIS) Design and Development Martha Powell, PhD Assistant Research Professor Division of Health Care Policy and Research September 13, 2012

Quality Indicator Survey (QIS)
Design and Development
Martha Powell, PhD
Assistant Research Professor
Division of Health Care Policy and Research
September 13, 2012
Presentation Overview
 University of Colorado’s role in
implementation and analysis of QIS
 Development and Implementation of the QIS
 Threshold development and review
 QIS in Indiana
University of Colorado Anschutz Medical Campus
2
CU’s Role
 Software design and testing
 Stage 1 and Stage 2 revisions/improvements
 Desk Audit Reports
 Threshold analysis
 Help Desk
 Onsite support for SA/RO
University of Colorado Anschutz Medical Campus
3
Survey Process
 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
University of Colorado Anschutz Medical Campus
4
History of QIS
 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
University of Colorado Anschutz Medical Campus
5
QIS Basics
 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
University of Colorado Anschutz Medical Campus
6
Stage 1
 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
University of Colorado Anschutz Medical Campus
7
QCLIs
 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)
University of Colorado Anschutz Medical Campus
8
Thresholds
 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 samples
University of Colorado Anschutz Medical Campus
9
Simplified QCLI Threshold Analysis
Survey
QCLI Rate
Cited?
19%
1
20%
N
2
20%
N
3
22%
N
4
35%
N
5
40%
Y
6
41%
N
7
50%
Y 
8
70%
Y 
University of Colorado Anschutz Medical Campus
If current threshold is 19%
8 – TRIGGERED and
3/8 or
10
3 – CITED
37.5% citation rate
Simplified QCLI Threshold Analysis
Survey
QCLI Rate
Cited?
19%
1
20%
N
2
20%
N
3
22%
N
4
35%
N
5
40%
Y
6
41%
N
7
50%
Y 
8
70%
Y 
University of Colorado Anschutz Medical Campus
If current threshold is 37%
4 – TRIGGERED and
3/4 or
11
3 – CITED
75.0% citation rate
Simplified QCLI Threshold Analysis
Survey
QCLI Rate
Cited?
19%
1
20%
N
2
20%
N
3
22%
N
4
35%
N
5
40%
Y
6
41%
N
7
50%
Y 
8
70%
Y 
If current threshold is 45%
2 – TRIGGERED and
2/2 or
University of Colorado Anschutz Medical Campus
12
2 – CITED
100.0% citation rate
Small/Not Small Sample Thresholds
 Census Sample
 Small: 35 or fewer residents
 Not Small: 36 – 40 residents
 Admission Sample
 Small: 9 or fewer residents
 Not Small: 10 – 30 residents
University of Colorado Anschutz Medical Campus
13
Stage 2
 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
University of Colorado Anschutz Medical Campus
14
QIS Surveyor Training
 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
University of Colorado Anschutz Medical Campus
15
QIS Implementation
University of Colorado Anschutz Medical Campus
16
QIS in Indiana




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
University of Colorado Anschutz Medical Campus
17
Triggered Care Areas
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 Services
University of Colorado Anschutz Medical Campus
18
Triggered Care Areas cont’d
 Indiana is a low outlier (compared to National QIS
rates) for:
 Physical Restraints and Positioning
 No high outliers for Indiana for triggered care
areas
University of Colorado Anschutz Medical Campus
19
Source of “Negative” Responses
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.
University of Colorado Anschutz Medical Campus
20
Citation Rates for Mandatory
Facility Tasks









Liability Notices
Dining
Infection Control
Kitchen
QA & A
Resident Council
Med. Admin
Med Storage
Unnecessary Med Use
University of Colorado Anschutz Medical Campus
25% (↑than Nat’l QIS)
23%
46% (↑than Nat’l QIS)
27%
13% (↑than Nat’l QIS)
13% (↑than Nat’l QIS)
13%
22%
39%
21
Citation Rates for Non-Mandatory
Facility Tasks






Abuse Prohibition
Adm, Tfr, DC
Environment
Personal Funds
Sufficient Nursing Staff
Extended Survey
23%
22%
74%
26%
13%
60%
Rates = # cited divided by # investigated (not total # of
surveys)
University of Colorado Anschutz Medical Campus
22
Citation Rates for Triggered CA/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 Positioning
University of Colorado Anschutz Medical Campus
23
Scope and Severity
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
A
B
C
D
E
F
G
H–L
University of Colorado Anschutz Medical Campus
Nat’l QIS
3.6%
4.8%
3.9%
64.3%
17.6%
3.2%
2.5%
0.2%
1.2%
2.7%
3.0%
65.3%
19.9%
4.8%
2.4%
0.55%
24
Most Frequently Cited F-tags
 Nationally in QIS states
F441 Infection Control -- 34.9%
F329 Drug Regimen free from Unecc. Drugs -- 34.1%
F323 Free of Accident Hazards -- 31.3%
 Indiana QIS
F282 Srvcs by Qualified Persons per Care Plan -- 44.7%
F323 Free of Accident Hazards -- 41.6%
F279 Develop Comp. Care Plans -- 41.1%
University of Colorado Anschutz Medical Campus
25
Citation Rates for Selected F-tags
F282
Nat’l QIS
IN QIS
diff
21.1%
44.7%
-23.6%
12.1%
28.9%
-16.9%
19.5%
32.0%
-12.5%
(Svcs by Qual. Pers per CP)
F156
(Notice of Rights)
F253
(Housekeeping)
University of Colorado Anschutz Medical Campus
26
Citation Rates for Selected F-tags
F280
Nat’l QIS
27.8%
IN QIS
22.3%
diff
5.5%
4.1%
5.8%
17.8%
6.5%
(Right to particp. In CP)
F281
9.9%
(Srvcs. meet Professional Stds.)
F272
24.4%
(Comprehensive Assessments)
University of Colorado Anschutz Medical Campus
27
Citation Rates for Selected F-tags
Nat’l QIS
IN QIS
3.2%
0%
F492
(Comply w/Fed/St/Local Laws/Prof. Stds.)
F274
1.6%
0%
1.2%
0%
(Comp. Assess. After Sig Change)
F497
(Nurse Aide Perform Rev-12 hr/yr in-service)
University of Colorado Anschutz Medical Campus
28
Citations and Survey Time
Nat’l QIS
IN QIS
Average Number of
Citations per Survey
6.9
8.4
Percentage of CitationFree Surveys
6.9%
9.6%
Survey Time (Prep,
Onsite, Offsite)
139.3
141.5
University of Colorado Anschutz Medical Campus
29
Contact Information
University of Colorado QIS website
http://www.ucdenver.edu/academics/colleges/medicalsch
ool/departments/medicine/hcpr/qis/Pages/default.aspx
CMS Project Officers
Susan Joslin ([email protected])
and
Tom Kress ([email protected])
University of Colorado Anschutz Medical Campus
30
Questions?
Martha Powell
[email protected]
(303) 724-2434
Sayuri Kelly
[email protected]
(303) 724-2490
For CMS QIS forms and Information:
https://www.qtso.com/qisdownload.html
University of Colorado Anschutz Medical Campus
31