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Watch for a Quality Indicator Survey coming near you

January 1, 2008
by RETA A. UNDERWOOD, ADC
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This year will see the expansion of a federal demonstration program that could lead to greater consistency and, hopefully, improvement in the state survey process. Initiated in 2005, principally in the state of Florida, the Quality Indicator Survey (QIS) program being conducted by the Centers for Medicare & Medicaid Services (CMS) is slated to spread into as many as six more states in 2008: California, Connecticut, Louisiana, Kansas, Ohio and, this month, Minnesota. What does it do?

Primarily, it uses resident information from the MDS 2.0 (table) in a system that classifies residents into homogeneous groups for equitable prospective payment and to monitor the quality of both the process and outcomes of care. Reports can be used by providers for assistance in self-monitoring their facility care quality. Using these Quality Indicators (QIs) and applying them to random samples of resident and new admission information, surveyors are expected to come up with consistent and useful findings for genuine quality improvement. In practice so far the demonstration has found the number of deficiencies cited increasing somewhat, but overall scope and severity declining.

Assessments Used for QI Reports

MDS 2.0 Section

QI Reports

A8a.—Primary reasonfor assessment

Facility

Facility Quality Indicator Profile

Resident Level Summary

1. Admission assessment

X

Excluded

X

2. Annual assessment

X

X

X

3. Significant change in X

X

X

status assessment

4. Significant correction X

X

X

of prior assessment

5. Quarterly review assessment

X

X

X

6. Discharged-return not anticipated

Excluded

Excluded

Excluded

7. Discharged-return anticipated

Excluded

Excluded

Excluded

8. Discharged prior to completing initial assessment

Excluded

Excluded

Excluded

9. Reentry

Excluded

Excluded

Excluded

10. Significant correction of prior quarterly assessment

X

X

X

0. NONE OF ABOVE

Excluded

Excluded

Excluded

The 24 QIs are based on the MDS 2.0 and cover the following domains: Accidents, Nutrition, Eating, Behavior/Emotional Patterns, Physical Functioning, Clinical Management, Psychotropic Drug Use, Cognitive Patterns, Quality of Life, Elimination/Incontinence, Skin Care, and Infection Control. Here, in plain language, is what these mean, based on a QI analysis from the Center for Health Systems Research and Analysis, University of Wisconsin–Madison:

QI 1 Incidence of new fractures

Residents who have a hip fracture or other fracture that is new since the last assessment. This QI is not risk-adjusted, and the denominator is all residents who did not have a fracture on the previous assessment.

QI 2 Prevalence of falls

Residents who have been coded with a fall within the time frame of the most recent assessment (past 30 days). Again, this QI is not risk-adjusted and the denominator is all residents.

QI 3 Prevalence of behavioral symptoms affecting others

A display of behaviors affecting others on the most recent assessment. Behavioral symptoms are defined as verbal abuse, physical abuse, or socially inappropriate/disruptive behavior. The behavior has had to occur at least once in the assessment period (7 days). This QI is risk-adjusted. Residents are considered more likely (are at HIGH RISK) to exhibit behavioral symptoms if they are cognitively impaired or have diagnoses of manic depression or psychotic disorders on the most recent assessment or on the most recent full assessment. Residents who do not have any of these conditions are described as LOW RISK.

QI 4 Prevalence of symptoms of depression

This is a complex definition. Residents are considered to have this QI if they have a sad mood and have two or more symptoms of functional depression. There are five symptoms, and some involve more than one item. Symptoms occurring within the most recent assessment period are: (1) negative statements exhibited up to five days or more per week; (2) agitation or withdrawal exhibited up to five days or more per week, or resists care at least 1-3 days in the last seven days, or withdrawal from activities or reduced social activity exhibited up to five days or more per week; (3) waking with an unpleasant mood up to five days or more per week, or not being awake most of the day and not comatose; (4) being suicidal or having recurrent thoughts of death up to five days or more per week; and (5) weight loss. This QI is not risk-adjusted and the denominator is all residents on the most recent assessment.

QI 5 Prevalence of depression with no antidepressant therapy

Residents with symptoms of depression and receiving no antidepressant therapy on the most recent assessment. Symptoms of depression are defined using the same criteria described above. This QI is not risk-adjusted and the denominator is all residents.

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