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

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

CU’s Role Software design and testing Stage 1 and Stage 2 revisions/improvements Desk Audit Reports Threshold analysis Help Desk Onsite support for SA/RO University of Colorado Anschutz Medical Campus

Survey Process Traditional QIS Both shaped by OBRA ‘87 Paper 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 ‘87 University of Colorado Anschutz Medical Campus

History of QIS 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 Evaluation National Implementation—phased approach University of Colorado Anschutz Medical Campus

QIS Basics Computer-assisted (tablets), 2 stages Stage 1: Preliminary Investigations Random sampling Structured protocols Stage 2: In-depth investigations Facility tasks (e.g., Kitchen, Infection Control & Immunization Review) Surveyor Initiation option Typically four surveyors onsite for 5 days University of Colorado Anschutz Medical Campus

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

QCLIs Quality of Care and Quality of Life Indictors Examples 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

Thresholds 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 benchmarks Reviewed and reset if appropriate Based on QIS data Separate threshold values for smaller census/admission samples University of Colorado Anschutz Medical Campus

Simplified QCLI Threshold Analysis Survey QCLI Rate Cited? 19% 1 20% N 2 3 22% 4 35% 5 40% Y  6 41% 7 50% Y  8 70% If current threshold is 19% 8 – TRIGGERED and 3 – CITED 3/8 or 37.5% citation rate University of Colorado Anschutz Medical Campus

Simplified QCLI Threshold Analysis Survey QCLI Rate Cited? 19% 1 20% N 2 3 22% 4 35% 5 40% Y  6 41% 7 50% Y  8 70% If current threshold is 37% 4 – TRIGGERED and 3 – CITED 3/4 or 75.0% citation rate University of Colorado Anschutz Medical Campus

Simplified QCLI Threshold Analysis Survey QCLI Rate Cited? 19% 1 20% N 2 3 22% 4 35% 5 40% Y  6 41% 7 50% Y  8 70% If current threshold is 45% 2 – TRIGGERED and 2 – CITED 2/2 or 100.0% citation rate University of Colorado Anschutz Medical Campus

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

Stage 2 In-depth investigations of triggered care areas and non-mandatory facility tasks Critical 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

QIS Surveyor Training 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

QIS Implementation University of Colorado Anschutz Medical Campus

QIS in Indiana First surveys conducted in January, 2011 As 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

Triggered Care Areas 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

Triggered Care Areas cont’d Indiana is a low outlier (compared to National QIS rates) for: Physical Restraints and Positioning No high outliers for Indiana for triggered care areas University of Colorado Anschutz Medical Campus

Source of “Negative” Responses 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

Citation Rates for Mandatory Facility Tasks 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

Citation Rates for Non-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

Citation Rates for Triggered CA/Tasks Indiana QIS similar to Nat’l QIS for most Indiana 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

Scope and Severity A 3.6% 1.2% B 4.8% 2.7% C 3.9% 3.0% D 64.3% 65.3% 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 QIS A 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

Most Frequently Cited F-tags Nationally in QIS states F441 Infection Control -- 34.9% F329 Drug Regimen free from Unecc. Drugs -- 34.1% F323 Free of Accident Hazards -- 31.3% Indiana QIS F282 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

Citation Rates for Selected F-tags Nat’l QIS IN QIS diff F282 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

Citation Rates for Selected F-tags Nat’l QIS IN QIS diff F280 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

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

Citations and Survey Time 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

Contact Information 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

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 University of Colorado Anschutz Medical Campus