State Performance Standards System

1. State Performance Standards System Bonnie Reed Dominick Esposito August 5, 2019

2. Introduction • Motivation for revising the SPSS • A multi-stakeholder effort • What the future holds…

3. Agenda • SPSS transformative changes and what it means for State Agencies • SPSS redesign schedule in FY2020 • State Performance Indicators • Input and feedback from you! • State-specific Measures • Input and feedback from you! • Questions and comments

4. Thank you for your feedback! • 44 States • 70+ Questionnaires • 60+ Conversations • Hundreds of emails • More than 500 pages of notes to review!

5. SPSS Transformative Changes Based on input from all SPSS stakeholders to improve SPSS consistency, relevancy, and effectiveness in service of improved quality of care for Medicare clients

6. Transitioning to a Quality Management System Transform the SPSS into a quality management system to help ROs and SAs identify potential areas of concern quickly, address state-specific concern areas, and improve SA performance/maintain high SA performance over time

7. SPSS Transformative Changes • State Performance Indicators • State-specific measure • SPSS Quality Domain • Quarterly Frequency Data

8. State Performance Indicators • Metrics that use SA survey data and other sources • CMS to construct/distribute to ROs and SAs • Quarterly reports/dashboard in a standard format • Provide information on where SA stands relative to national average/median as well as peer group • ROs and SAs collaborate to proactively identify potential areas of concern • Encourage ongoing discussion on data-driven indicators • Assess performance in real-time; links to metrics in SOAR reports for LTC survey process • Phased roll out process including SAfeedback today

9. State-specific Measure • New, scored measure focused on making improvement in States’ potential areas of concern • State Performance Indicators are first-line candidates for a State-specific measure • Already constructed for ROs and SAs and relevant to performance • Other agreed upon measures may also be relevant • A State-specific measure may not be necessary for all SAs in every year • Encourage improved quality management over time • Phased roll out process including SAfeedback today

10. SPSS Quality Domain Improving consistency, reducing subjectivity, and encouraging improvement in SA performance

11. SPSS Quality Domain • Revised the documentation of deficiencies (Q1) to improve consistency, reduce subjectivity, and reduce burden • RO review committee approach established to improve consistency across regions • Revised language to make criteria less subjective • Reduced the number of criteria to reduce burden • June 2019 – pilot of revised Q1 criteria, and revised processes for both Q1 and Q6.

12. Revised Q1 Criteria • There is sufficient evidence on the CMS-2567 to support a citation • The appropriate regulation was cited based on the evidence provided on the CMS-2567 • Nursing homes only: There is sufficient evidence to support the assigned severity rating as documented on the CMS-2567 • Nursing homes only: The scope rating of the citation accurately reflects the number of residents who are, or may be, affected by the deficient practice as documented on the CMS-2567 • Non-nursing homes only: The level of citation (Condition, Standard, or Element level) accurately reflects the evidence presented as documented on the CMS-2567

13. Other Changes in the Quality Domain • Global changes in the Quality Domain • Review less frequently if SA performs well consistently and SPSS is implemented successfully • Increase sample size for review if SA does not perform well. • This will minimize small sample bias and identify potential areas of concern

14. Quarterly Frequency Dashboard

15. Quarterly Frequency Dashboard • Possible display of Frequency measure run rates for a Region to review. • Same view provided for each SPSS Frequency measure. • Can be created directly from existing data.

16. Quarterly Frequency Dashboard

17. State-level Frequency Reports Summary by Provider Type for Surveys and Timeliness

18. State Performance Indicators A step towards becoming more data-driven

19. Why State Performance Indicators? • Identify potential areas of concern proactively • Encourage ongoing communication between ROs and SAs on data-driven indicators • Understand SA performance in real-time • Link to metrics in SOAR reports for LTC survey process; similar metrics for NLTC

20. What are State Performance Indicators? • Metrics based on SA survey data and other sources • Quality Domain • Standard Surveys • Intake Surveys • Coordination of Provider Noncompliance (i.e. Enforcement) • Resource Management • CMS to create reports for SAs and ROs quarterly in a standard, user-friendly format • Information on where SA stands relative to national average, median, and peer group • Summaries across all domains, indicators, and providers

21. State Performance Indicators • Example metrics for Intakes: • Intakes per provider by facility census • Allegation rate by facility census • Allegation reoccurrence rate • Intake prioritization distribution • Allegation citation rate • Outlier values do not automatically imply there is a problem • further investigation and discussion may be needed • Data provides opportunity to encourage collaboration and identify potential areas of concern that SAs and ROs might overlook

22. State Performance Indicator Report

23. Time to get interactive! State Performance Indicators • Exercise: Review the State performance indicator report mock-up • Is this format helpful? • Are there potential indicators that you might also want to see or that you use in your State? • Other discussion questions: • What do you like? • What is missing? • Report out • Nominate a group member to share your thoughts

24. State-specific Measure Encourage investigation of potential concern areas to improve State performance

25. State-specific Measure • Scored measure focused on making improvement in States’ potential areas of concern • Investigate potential areas of concern for root causes • Develop plan for improvement • Establish and measure improvement goals • Pilot and assess usefulness, relevance, and value in FY2020 • A State-specific measure may not be necessary in all States in every year • State Performance Indicators are first-line candidates for a State-specific measure • Already constructed for ROs and SAs and relevant to performance • Other agreed upon measures may also be relevant

26. State-specific Measures Improve State performance in service of higher quality care

27. Example: State-specific measure • Area of concern: Citation rates among intake allegations are consistently lower than median nationally and lean towards lowest among all States Performance Improvement Plan • Actionable objective: State the goal of the activity to be conducted • Measurable outcome: Citation rate among intake allegations • Action Plan: Document the actions taken to carry out the performance improvement plan • RO responsible for two-pronged assessment • Reviews actions taken by the SA to implement plan • Reviews measurable outcome to determine progress

28. Time to get interactive! State-specific Measure • Exercise: Your SA team seeks to work with your RO on an agreed upon area of concern • Do the materials/templates provided help guide you on next steps with your RO? • What is missing that would be helpful to you and your team? • Other discussion questions: • Thoughts on the format of the materials: • What do you like? What is missing? • Will the process help take a step towards SPSS as a quality management system? • Report out

29. Questions and Comments Are we moving in the right direction? Direct line to the project team with any questions or comments: spss@insightpolicyresearch.com