The Quality Indicator Survey Process (QIS)

1. The Quality IndicatorSurvey Process(QIS) Care Providers of Minnesota Board of Directors Meeting March 15, 2007

2. QIS • Developed by the University of Colorado, University of Wisconsin (CHSRA), Maverick Systems, and Alpine Technologies under contact with Research Triangle. • Developed from 1998-2005, refinements since.

3. Pilots to-date • Piloted in 5 states between October 2005 and October 2006: • California • Connecticut • Kansas • Louisiana • Ohio Conducted over 170 QIS surveys for evaluation

4. Expansion of Pilots • In December 2006 CMS sent out a solicitation to all non-pilot states informing them of the expansion of the QIS pilot. • No specific number of additional states identified • CMS estimates expansion into the expanded states would commence in the fall of 2007 • MDH has applied for inclusion in the expansion • The MDH application was supported by Care Providers of Minnesota’s Regulatory Committee and Executive Management Committee.

5. What is the QIS? • A different, more automated, data driven method to survey for compliance with Federal Regulations. • QIS Objectives: • Improve the consistency and accuracy of surveys using a structured process • Comprehensively survey all regulations • Enhance documentation through automation • Focus survey resources on facilities with the largest umber of quality concerns • Do it all within existing survey and certification budgeted resources

6. Offsite Preparation Facility Tour Entrance Conference Stage 1 Sample Selection (3 Samples: MDS based, Admission, Census Stage 1 Sample Review (Resident, Family, & Staff interviews, Resident Observations, Medical Record Reviews) Exit Conference Facility-Level Investigations Medication Adm Observation Stage II Investigation Identify care deficiencies and determine S/S of deficiencies

7. How Does the QIS Work? • Offsite Survey Preparation • Review of facility history, complaints, and ombudsman reports (nothing new here) • Surveyors pre-load all facility MDS’s into their computers (new) • No review of QM’s, QI’s, or OSCAR reports to pre-select a resident sample (new)

8. Entrance Conference • Roster/Sample Matrix (CMS 802) no longer required • Must provide resident census in alphabetical order (incl room #’s and units) • Must provide closed admission records within one hour

9. Tour • Brief overview of the facility • Used to get a sense of the facility and residents • Not intended to augment the resident sample or to begin investigations

10. Stage 1 Samples • MDS Sample – includes all residents with an MDS assessment within the past 6 months • Census Sample – Random sample of 40 current residents • Admission Sample – Random sample of 30 recent admissions • Surveyor Sample – Initiated sample at surveyors’ discretion

11. Advantages of Stage 1 Samples • MDS Sample – covers all residents (except very recent) but is only facility-reported information • Census Sample – emphasizes long-stay residents because it is cross-sectional…primary observation information • Random Admission Sample – captures post-acute admissions

12. Resident Interviews • Surveyors will use the Cognitive Performance Scale (CPS) from the downloaded MDS data to calculate which residents are interviewable: • CPS Score 1-3: Interviewable • CPS Score 4-7: Family Interview Candidate If resident has no MDS they will be listed as interviewable until otherwise determined

13. Resident Interviews • General Questions… • Are you from here? Tell me about yourself? How long have you been here? What food do you like here?, etc. • Required Structured Questions… • Choices, Dignity, Activities, Building & Environment, Participation in Care Plan, Abuse, Interaction with others, Personal property, Pain, ADL assistance, Food quality, Hydration, Sufficient staff, Privacy, Exercise of rights, Personal funds.

14. Resident Observations • Cleanliness, Grooming, Oral health, Incontinence, Dressing, Activities, Contractures, Abuse, Skin, Restraints, Pain, Hydration, Positioning, Accident hazards, Siderails, Resident room condition.

15. Overall Facility-Level Investigations • Tasks completed on every survey: • Resident Council representative interview (no more group interview) • Dining observation • Kitchen/Food Services observation • Infection control • Demand billing • Quality Assessment and Assurance review

16. Overall Facility-Level Investigations • Tasks if triggered by Stage 1 Findings (resident/family/staff interviews, resident observations, & medical record reviews) • Abuse Prohibition review • Admission, Transfer, & Discharge review • Environment • Resident Funds • Sufficient Staff

17. Then Everything Gets Dumped into One Computer • Each surveyor downloads documentation from their tablet computers onto a flash drive and combines all surveyor data onto the Team Leader’s computer.

18. Data Driven • The QIS Data Collection Tool (DCT) calculates the Quality Care Indicators (QCIs) • There are a total of 160 QCIs and Facility level tasks: • 44 MDS (includes the 24 quality indicators) • 68 Census • 6 Administration • 42 Facility

19. Data Driven • The facility-specific QCIs are calculated and compared to national rates • If the rates exceed the established thresholds, and in-depth investigation of those care areas is conducted (State II) • Stage II resident samples are selected by system software • State II investigation is required to determine if there are deficient practices

20. Stage II • Evaluate Care Practices in relation to Stage I findings • Resident-level and facility-wide • Medication Administration Observation • Use of Critical Element Pathways to structure the investigative process(Activities, ADLs, ROM, Behavior, B&B, Communication, Dental, Dialysis, Hospitalization, Death, Nutrition, Hydration, Tube Feeding, Pain, Restraints, Pressure Ulcers, Medications, Rehab and Community discharges, Vents) • Integrates information from multiple data sources • Rate severity for each resident where deficient practice is found

21. Surveyor Team Meeting • Discuss: Staff-to-resident interactions, availability of staff and staffing patterns, activities observed, characteristics of resident population, meal times, scheduled activities, and medication pass times, residents with unmet needs. • Surveyors will be assigned to observe various meal times in dining areas and resident rooms if deemed appropriate.

22. Regulatory Determination • Combine Stage II findings across residents by F-Tag • Integrates survey team findings into a single statement • Uses documentation from Stage I and Stage II findings • Identifies deficiencies and determines scope and severity • Exit Conference

23. Offsite Preparation Facility Tour Entrance Conference Stage 1 Sample Selection (3 Samples: MDS based, Admission, Census Stage 1 Sample Review (Resident, Family, & Staff interviews, Resident Observations, Medical Record Reviews) Exit Conference Facility-Level Investigations Medication Adm Observation Stage II Investigation Identify care deficiencies and determine S/S of deficiencies

24. QIS Process Strengths • Larger Sample Sizes – it requires a sample of adequate size to infer anything about the population…plus different samples are used (admission, census, mds, etc.) • Comprehensive – past studies have demonstrated that some surveyors focused only on select deficiencies – Structured approach requires surveyors to examine all regulations

25. QIS Process Strengths • Structured Approach – Systematic observations and questions are comparable across all sites and are replicable…providers could potentially also used the tools to improve regulatory compliance • Enhanced Documentation – Information collected throughout the process is collated by computers for development of the 2567…Trail of findings available to follow on-site decision-making

26. Questions?