The Quality Indicator Survey

(QIS)….

Joy Jordan RN, MSN National Director of Quality Surveys

Boyer & Associates, LLC 16655 W. Bluemound Road, Suite 280

Brookfield, WI 53005 www.boyerandassociates.com

Presentation Leading Age Missouri Sponsored by McKesson

Comparison of

Traditional

Survey Process

QI Survey VS

Off- Site Survey Prep Traditional Survey

Review Survey History & Resident Characteristics (OSCAR 3 & 4)

Review any complaints

Review QI/QM reports

Preliminary Sample Selection

QI Survey Review Survey History

(OSCAR 3)

Review any complaints Download MDS data

Stage I random sample

selection

Entrance Conference Traditional

Resident Roster Sample Matrix (CMS 802)

QI/QM report

QI Survey Alphabetical resident

listing identifying room numbers/units

List of new admissions in last 30 days

Items needed within one hour/4 hours/24 hours

Facility Tour Traditional

Validate or invalidate off-

site survey concerns

Identify residents on sample and determine if still appropriate

Identify any new residents or concerns

QI Survey

Initial brief overview of the facility

Identify staff/resident interactions

No sample selection

Sample Selection Traditional

Pre-selected during off-site prep based on flagged QI/aQMs

Size of sample dependent on facility size

QI Survey Random sample

selection

Three Samples MDS

Admission (30)

Census (40)

Surveyor initiated

sample

Structure of Survey Process Traditional

Phase I – comprehensive & focused reviews

Phase II – focused reviews

QI Survey Stage I – preliminary

investigation of regulatory issues, random selection

Stage II – in-depth investigation of Care Areas based on exceeding thresholds in Stage I

Survey Review Process Traditional

Review completed by utilizing QIs/Resident Roster information

Appendix PP Investigative Protocols used

QI Survey Structured interviews,

observations and clinical record reviews

Structured protocols for facility tasks

Critical elements for Stage II quality of care & quality of life areas

Group Interview Process Traditional

Meet with Resident Council/Group

Review of resident council minutes to identify areas of concern

QI Survey Interview with Resident

Council President or representative

Areas of review similar to traditional survey group questions

Survey Automation Traditional

Paper process throughout the survey

Computers only used for 2567 – Statement of Deficiencies

QI Survey Automated process

Surveyors utilize PCs to

gather information

Computer analyzes information for thresholds, suggested F tags

Findings uploaded to 2567

Culture Change Traditional

Focus on regulations

Quality of Care

QI Survey Focus on resident

preferences

Quality of Life in addition to Quality of Care

Other Survey Differences Traditional

Length – varies depending on number of team members

Lots of inconsistency from State to State and sometimes within a State

More subjective process throughout survey

QI Survey Length – varies from three

days to more than a week

Typically completed within one week

Can still have a Zero Deficiency survey

Generally increase in # of deficiencies – particularly in Quality of Life Areas

Decrease in S/S

Stage I – more objective process

Quality Indicator Survey Tasks Task 1 - Offsite Survey Prep & Initial Sampling

Task 2 – On-site Survey & Entrance Conference

Task 3 – Initial Tour

Task 4 – Stage I Survey Tasks

Task 5 – Non-Staged Survey Tasks

Quality Indicator Survey Tasks

Task 6 – Transition from Stage I to Stage II

Task 7 – Stage II Survey Tasks

Task 8 – Analysis & Decision Making: Integration of Information

Task 9 – Exit Conference

Offsite Survey Prep MDS loaded onto PCs

Review past deficiencies

Review any complaints to be investigated

Review Ombudsman information

Onsite Survey Prep Entrance conference – 1 person

Facility Tour – 2 people

Reconcile Stage 1 sample – uses alphabetical list of residents & new admission information- not the roster

Onsite Survey Prep Information needed immediately

Alphabetical resident listing with room numbers/units

New Admission Information form

Facility floor plan

Staffing schedules for licensed and registered nursing staff

Entrance Tour Change from the Traditional Survey process

Brief overview of the facility

Sense of the facility & its resources

Entrance Conference and Initial Tour Request for alphabetical resident census and list of

newly admitted residents within last 30 days (New Admission Information form)

Request for information on meal times, med administration

Request facility floor plan

Staffing schedules for LPNs/RN staff

Request information on residents with complex care** Ventilators Dialysis Hospice/End of Life

Resident Samples Four Sample Types

Admission Sample – random sample of new admissions (n=30)

Census Sample – random sample of current residents (n= 40)

Surveyor sample – initiated at surveyors discretion

MDS Sample – all residents with an MDS in the past six months

MDS Sample

MDS Sample – reflects quality of care data on all residents treated in the facility during a time frame

Limited to facility reported MDS data

All assessment types except Discharge assessments

Excludes residents who only had an Admission assessment in the 180 day period

Not used during Stage 1 – used in Stage 2 for residents triggering MDS based QCIs

Stage I Preliminary Investigation

Admission Sample

Clinical Record Reviews

Census Sample

Resident Interviews & Observation

Family Interviews

Staff Interviews

Clinical Record Reviews

Census Sample – Resident Interview

Choices Activities Participation in Care Plan Interaction with others Pain Hydration Oral Health Exercise of Rights

Dignity Building & Environment Abuse Personal Property Food Quality Sufficient Staff Privacy Personal Funds

•Interviewable vs. Non-interviewable

•Probe questions & Cognitive Performance Scale

•Conducted for all Stage I Census Sample residents

•Variety of Areas Reviewed

Census Sample – Resident Observation

Cleanliness/Grooming

Dressing

Contractures

Skin Problems

Pain

Positioning

Resident Room

Incontinence

Activities

Abuse

Potential Restraints

Hydration

Potential Safety Hazard (Bed Rails

Completed for all census sample residents

Census Sample – Family Interview

Completed for non-interviewable residents

Interview someone who has knowledge of the resident’s day-to-day activity

Visits the resident frequently

Same types of questions as resident interview

Complete 3 family interviews in each survey

Census Sample – Staff Interview Interview of Staff Member assigned to resident Surveyor will make appointment with nurse Staff will need resident diagnosis, MAR/TAR, skin

flowsheets, weights available Six key areas

Catheter use – reason for usage Nutrition – supplement use – need to verify Skin care/Pressure Ulcer – Number & Stage Side Rails Contractures Fall & Fractures

Census Sample – Record Review All 40 census sample residents

Reviews conducted on the nursing unit to allow for observation

MDS Items – Comatose, bed mobility, transfer, specific nutritional dx, stability of conditions

Pressure Ulcers – Stage of most advanced

Psychotropic Medications

Benzodiazepine or Antipsychotic

Diagnosis to support

Census Sample – Record Review Height & weight

Weight

Weight closest to today’s date

30 days prior

90 days prior

180 days prior

DCT determines percentage of weight loss

Admission Sample Record Review – Can be open or closed records

Community Discharge – excludes terminal diagnosis residents ▪ Discharge location

Rehabilitation Services Admission source Death Hospitalization Pressure Ulcer

▪ Admission vs developed within 30 days ▪ Worsening of pressure ulcer

Weight Loss (DCT automatically calculates % weight loss) ▪ Admission date ▪ 15 days after admission ▪ 30 days after admission ▪ 60 days after admission

Stage I Mandatory Tasks

Demand Billing

Dining Observation

Infection Control & Immunization

Kitchen/Food Service Observation

Medication Administration/Drug Storage

Quality Assessment & Assurance (QA&A)

Resident Council President/Representative Interview

Transition from Stage I to Stage II

Surveyors merge data

QCIs are calculated and compared to national rates

If rates exceed thresholds, in-depth investigation required

Stage II Sample selected

What is a Threshold The rate established by national norms to determine

the decision whether or not to conduct a Stage II investigation.

Care Area Investigations

Specific Critical Element Pathways

General Critical Element Pathway

Guidance to Surveyors from State Operations Manual

Triggered Facility-level Tasks

Stage II In-Depth Review Information gathering includes quality of care and

quality of life probes:

Resident/family interviews

Resident Observations

Staff Interviews

Necessary Record Reviews

Critical Element Pathways used to guide the reviews and to assist surveyors in completing a consistent, organized, and systematic review of triggered care areas (16 specific and a general CE Pathway)

Triggered Critical Element Pathways Activities ADLs/ROM/ Cleanliness

& Grooming & Positioning

Behavioral and Emotional Status

Bowel or Bladder Function/ Indwelling Catheter

Communication/Sensory Problems/Hearing/Vision

Dental Status and Services

Hospitalization or Death Nutrition/Hydration/Tub

e Feeding Pain Management Physical Restraints Pressure Ulcers Psychoactive Medications Rehabilitation/

Community Discharge General Critical Element

Pathway

General Critical Element Pathway Used for Care Areas without a Specific Critical

Element Pathway

Accidents

Fecal Impaction

Non- pressure ulcer skin conditions

Infections other than UTIs

Stage II Investigations

Both resident level & facility level

Critical Element Pathways

Integrate information from various data sources

Rate severity of deficient practice

Stage II Facility Level Tasks

Only completed if triggered by Stage I Abuse Prohibition

Admission, Transfer, and Discharge

Environmental Observations

Personal Funds

Sufficient Nursing Staff

Quality of Care Indicators

Definition

Resident Centered Outcome

& Process Indicators

Quality of Care Indicators

162 Quality of Care Indicators

51 Care Areas

47 related to the MDS

Critical Element Pathways Definition

Investigative protocols corresponding to Care Areas that guide the surveyor through an investigation

to determine whether the facility meets the regulatory requirements

Incorporates resident care process

Resident Outcomes

1. Use Critical Element Pathways as Quality Improvement Tools

2. Use the Resident Interview Tools routinely 3. Get staff involved in completing tools for self

evaluation