Quality Indicator Survey (QIS) Design and Development - PowerPoint Presentation

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

University of Colorado’s role in implementation and analysis of QISDevelopment and Implementation of the QISThreshold development and review QIS in Indiana University of Colorado Anschutz Medical Campus 2 Presentation Overview

Software design and testingStage 1 and Stage 2 revisions/improvementsDesk Audit ReportsThreshold analysis Help Desk Onsite support for SA/RO University of Colorado Anschutz Medical Campus 3 CU’s Role

TraditionalPaper 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 ‘87University of Colorado Anschutz Medical Campus 4 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 EvaluationNational Implementation—phased approach University of Colorado Anschutz Medical Campus 5 History of QIS

Computer-assisted (tablets), 2 stages Stage 1: Preliminary InvestigationsRandom sampling Structured protocols Stage 2: In -depth investigationsFacility 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 QIS Basics

Census Sample (N=40): Resident Interview/ObservationStaff Interview Record Review Family Interview (n=3) Admission Sample (N=30):recently-admitted residentsRecord Review MDS Sample: assessments from prior 180 days University of Colorado Anschutz Medical Campus 7 Stage 1

Quality of Care and Quality of Life IndictorsExamples 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 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 benchmarksReviewed and reset if appropriateBased 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% 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 10 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% 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 11 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% 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 12 Simplified QCLI Threshold Analysis If current threshold is 45% 2 – TRIGGERED and 2 – CITED 2 / 2 or 100.0% citation rate

Census SampleSmall: 35 or fewer residentsNot Small: 36 – 40 residents Admission Sample Small: 9 or fewer residents Not Small: 10 – 30 residentsUniversity of Colorado Anschutz Medical Campus 13 Small/Not Small Sample Thresholds

In-depth investigations of triggered care areas and non-mandatory facility tasksCritical 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 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 University of Colorado Anschutz Medical Campus 15 QIS Surveyor Training

University of Colorado Anschutz Medical Campus 16 QIS Implementation

First surveys conducted in January, 2011As 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 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 Services University of Colorado Anschutz Medical Campus 18 Triggered Care Areas

Indiana is a low outlier (compared to National QIS rates) for:Physical Restraints and PositioningNo high outliers for Indiana for triggered care areas University of Colorado Anschutz Medical Campus 19 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. University of Colorado Anschutz Medical Campus 20 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%University of Colorado Anschutz Medical Campus 21 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) University of Colorado Anschutz Medical Campus 22 Citation Rates for Non-Mandatory Facility Tasks

Indiana QIS similar to Nat’l QIS for mostIndiana 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 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% University of Colorado Anschutz Medical Campus 24 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 % University of Colorado Anschutz Medical Campus 25 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) University of Colorado Anschutz Medical Campus 26 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) University of Colorado Anschutz Medical Campus 27 Citation Rates for Selected F-tags

Nat’l QIS IN QIS F492 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) University of Colorado Anschutz Medical Campus 28 Citation Rates for Selected F-tags

Nat’l QIS IN QIS Average Number of Citations per Survey 6.9 8.4 Percentage of Citation- Free Surveys 6.9% 9.6% Survey Time (Prep, Onsite, Offsite) 139.3 141.5 University of Colorado Anschutz Medical Campus 29 Citations and Survey Time

University of Colorado QIS website http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/hcpr/qis/Pages/default.aspx CMS Project Officers Susan Joslin (Susan.Joslin@cms.hhs.gov)and Tom Kress (Thomas.Kress@cms.hhs.gov)University of Colorado Anschutz Medical Campus 30 Contact Information

University of Colorado Anschutz Medical Campus 31 Questions? Martha Powell Martha.Powell@ucdenver.edu (303) 724-2434 Sayuri Kelly Sayuri.Kelly@ucdenver.edu (303) 724-2490 For CMS QIS forms and Information: https:// www.qtso.com/qisdownload.html