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Update on the Quality Indicator Survey

March 19, 2008
by Richard L. Peck
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An interview with Andrew Kramer, MD, President and CEO, Nursing Home Quality LLC, and Professor of Medicine at the University of Colorado

For a long-term care industry yearning for an alternative—any alternative—to the OBRA state survey system that gives facilities such trouble in terms of consistency, collaborativeness and fairness, one of the more intriguing changes underway is the Quality Indicator Survey (QIS). Initiated as a demonstration program in 2005 by the federal Centers for Medicare and Medicaid Services (CMS) through a contract with the University of Colorado, this wide-ranging new process first became established in six states (Connecticut, Kansas, Florida, Louisiana, California and Ohio).
Following the successful demonstration, CMS began national roll out of the QIS with statewide expansion in five of these states, the addition of Minnesota in early 2008, and with the expectation of three more states starting this summer. Nursing Home Quality LLC is the contractor responsible for training the state survey agencies in QIS for the national roll out. Rumors—and misconceptions—are flying about its results in nursing facilities and how they compare with current survey and QI/QM processes. Recently Andrew Kramer, MD, who leads the University of Colorado and the Nursing Home Quality teams in QIS, addressed a few commonly asked questions in this exclusive online interview with Long-Term Living Editor-in-Chief Richard L. Peck.

Peck: How does the QIS in fact compare with the state survey system?

Dr. Kramer: Several points come to mind: First, it’s more resident-centered, with more information obtained from direct questioning of residents and families, not about satisfaction, but about quality of life and quality of care. Second, QIS is a more structured process, with all investigations following more structured protocols that are fully automated on tablet PCs. Third, QIS involves a much larger sampling of residents, so that no one resident’s experience drives the whole process. Fourth, the process is easily replicated by nursing facilities and gives them a convenient way to manage their quality and improve survey performance.

Peck: QIS now uses MDS 2.0 as a basis for some of its work—will it use MDS 3.0 when (and if) it’s released in October 2009?

Dr. Kramer: Yes, it will. However, even with the greater use of resident interviews planned for 3.0, QIS interviews and investigations will be much more extensive than laid out by the MDS. The MDS never was designed to be a basis for the survey process and does not cover the complete code of regulations. The MDS is probably less than 25% of the material covered by QIS.

Peck: What about the QI (Quality Indicator) and QM (Quality Measurement) reporting that facilities now do under CMS’s Nursing Home Quality Initiative? How does this relate to QIS?

Dr. Kramer: The QIs and QMs are important but, again, don’t cover all the dimensions of quality. It’s entirely possible for people to have excellent QIs and QMs and still end up with a poor survey. That’s why Quality Indicator Survey may not have been the best choice of names—it does open things up to confusion. In fact, QIS uses “quality of care and quality of life indicators,” or QCLIs, a term you will see increasingly in the literature based on resident, family and staff interviews, resident observations, and chart reviews. Only about 25% of the QCLIs come from the MDS, as already mentioned, and 13% from the QI/QM process. That means the vast majority of the QIS goes beyond the traditional quality initiatives and concepts with which the field is most familiar.

Peck: Rumor has it that, among the states in which QIS is up-and-running, deficiencies have tended to increase but scope and severity have decreased. Is this an accurate summary?

Dr. Kramer: Not really. In 40% of surveys deficiencies have been about the same or fewer, and every QIS state has had zero deficiency surveys. That said, the remaining 60% of facilities have had more deficiencies in QIS than in their prior traditional survey, often in regulatory areas such as quality of life that were not as fully investigated in the traditional process. There may be a perception of increased deficiencies across the board because QIS gets into much broader patterns of care. Proportionally, there are fewer of the isolated cases that one finds in the traditional survey process. On the other hand, QIS more fully addresses areas in the code of regulations that have never been adequately assessed before.

Peck: With six states already underway, what is the rollout schedule for QIS?

Dr. Kramer: CMS plans on three more states starting this summer, although they haven’t been identified yet. The process is very budget-driven and the rate of the roll out in each state is dependent on the resources that the state can commit and the number of surveyors in the state who need to be trained in QIS. For example, Connecticut is already statewide with the relatively small number of surveyors in the state, but Ohio and Florida are rolling QIS out over about three years.

Peck: What about providers who are in inactive states and would like to become involved with the QIS process?

Dr. Kramer: This was why we started Nursing Home Quality, LLC, in the first place. We have created tools that will help providers prepare and do well with both the QIS and with the traditional survey, and we provide training at various levels of intensity—one-day, two-day, and four-day—for providers to conveniently and affordably learn how to use these tools. We have trained more than 3,000 providers thus far. For further information, they should visit