For years, long-term care providers have been asking for a change in the state survey process. They have asked for a more consistent, accurate and consolidated survey that would be uniform across all states. The wait is almost over.

 

The new Quality Indicator Survey (QIS) is in the initial stages of roll out and implementation across the country with hopes of being fully implemented nationwide within three years. The four main objectives of the QIS are:

 

 

1. Improve consistency and accuracy of the survey process.
2. Comprehensively review more regulatory areas within current survey resources.
3. Enhance documentation through automation.
4. Focus survey resources on facilities with the greatest quality concerns.

 

History of QIS

 

In 1993, Dr. Andrew Kramer and a team of researchers from the University of Colorado developed a two-stage quality assessment approach to review quality of care and life in nursing homes.  In 1994, the initial test of the approach as a survey process was conducted by Colorado and Massachusetts surveyors. Dr. Kramer and his research team continued to use and refine the two-stage quality assessment for research, which led to a contract with the Centers for Medicare and Medicaid Services (CMS).  Within this contract, Dr. Kramer's team and the University of Wisconsin were tasked to expand the two-stage quality assessment process to include more regulatory areas. This contract was completed in 2003 and resulted in the QIS, which was automated for state surveyor use by CMS.

 

In 2005, CMS initiated a demonstration program to evaluate the ability of QIS to improve the survey process. Initially, the demonstration project was established in six states (Connecticut, Kansas, Florida, Louisiana, Ohio and California) and was proven successful. CMS began a national roll out of QIS with statewide expansion in five of the demonstration states and in Minnesota in January 2008.

 

 

QIS is a revised long-term care survey process that involves two stages of review. In the first stage, preliminary investigations are conducted through structured resident, family, and staff interviews; resident observations; record reviews and analysis of Minimum Data Set (MDS) data. These tasks, in combination with facility reviews, yield 128 Quality of Care and Quality of Life Indicators (QCLIs) and 34 facility level QCLIs. These are compared to national norms to identify Care Areas for further investigation in the second stage of the QIS survey. The Care Areas are mapped to specific F-tags that identify deficiencies within the facility.

 

How is QIS Different?

 

The QIS survey process is more resident centered than the traditional survey method, with information gathered from direct structured interviews with residents and families about the quality of care and life. QIS is a controlled process that includes a larger sample of residents selected randomly, and incorporates investigations that follow structured protocols that are fully automated. MDS 2.0 data is also incorporated into the QIS data, but overall, it comprises less than 25 percent of the material covered by QIS. MDS 3.0 will replace MDS 2.0 data when it is released in October 2009.

 

During the research and development of QIS, Quality Indicator (QI) and Quality Measurement (QM) data were reviewed and found that they didn't cover all of the dimensions of quality. The QI and QM data comprises about 13% of the QCLIs in the QIS process. The main sources of QCLIs are resident, family and staff interviews, resident observations, and chart reviews. Experience from the QIS demonstration states have found that the care areas triggered during stage one of the QIS for additional investigation in stage two areas triggered are derived from resident interviews (21%), resident observation (16%), MDS QIs (13%), family interviews (12%), new MDS indicators (11%), admission chart reviews (10%), staff interviews (9%), and current resident chart interviews (8%).

 

QIS Deficiencies

 

In QIS states, 40% of facilities experiences deficiencies at the same level or less than deficiencies generated from the traditional survey process. 60% of facilities had more deficiencies in QIS than they had from prior traditional surveys, often in quality of life areas that were not traditionally investigated in the traditional survey process. Examples of deficiencies cited at higher rates in QIS include:

 

Preparing for QIS

 

Although the QIS was designed for surveyors to conduct the Federal survey, the two-stage quality assessment tools that are used in the QIS are available at no cost to providers. They can serve as the basis for continuous survey readiness and for a comprehensive quality improvement (QI) and quality assurance (QA) system.  The QIS system is most beneficial if it becomes part of the facilities systems and process and is used throughout the year, not only at survey time. If used correctly, these tools can assist nursing homes in assessing their residents' quality of care and quality of life using the same tools and processes that are used by QIS surveyors. Nursing homes are able to develop processes to collect information through structured interviews with residents, residents' families, and staff members. The data derived from these interviews, along with information obtained through structured observation and record review, can change the QA/QI process and focus activities that will provide for continuous survey readiness and ongoing quality improvement.

 

Diane Peters

RN, NHA, MS, Director of Leadership and Quality Initiatives

 

The forms and tools used as the basis of the assessment by surveyors can be downloaded at: http://www.uchsc.edu/hcpr/qis_forms.php.

 

CMS has designated the University of Colorado's Division of Health Care Policy and Research Web site as the official source of the most up-to-date versions of the Quality Indicator Survey (QIS) Resource Manual and forms.  The QIS Resource Manual, which is provided to state surveyors during QIS Training, is accessible on this Web site through the following link: http://www.uchsc.edu/hcpr/qis_manual.php.

 

Pathway Health Services (PHS) Resources and Consultation

 

Diane Vaughn, Regional Director of Minnesota and Diane Peters, Director of Leadership & Quality Initiatives, have recently completed an intensive QIS course and are in the process of becoming certified as QIS trainers.

 

Pathway Health Services in Minnesota will begin offering courses on the QIS process at the Fireside Education Center in White Bear Lake on April 11th, May 9th and June 13th.

 

The initial Perspectives teleconferencing and e-learning QIS course will be offered on June 5th from 3:00-4:00PM, Central Standard Time.

 

Onsite education and consultation on QIS and integration of QIS tools and processes into your QI/QA systems is available for corporations and individual nursing homes. To obtain more information, please e-mail consult@pathwayhealth.com