Quality Indicator Survey QIS Design and Development Martha

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Quality Indicator Survey (QIS) Design and Development Martha Powell, Ph. D Assistant Research Professor

Quality Indicator Survey (QIS) Design and Development Martha Powell, Ph. D 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

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 2

CU’s Role Software design and testing Stage 1 and Stage 2 revisions/improvements Desk Audit

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 3

Survey Process Traditional Paper forms, prelim sample from QM/QI, tour used to supplement sample,

Survey Process Traditional 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 4

History of QIS Pre-cursor to QIS (Quality Indicator Survey) developed to serve as standard

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 5

QIS Basics Computer-assisted (tablets), 2 stages Stage 1: Preliminary Investigations Random sampling Structured protocols

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 6

Stage 1 Census Sample (N=40): Resident Interview/Observation Staff Interview Record Review Family Interview (n=3)

Stage 1 Census Sample (N=40): Resident Interview/Observation Staff Interview Record Review Family Interview (n=3) Admission Sample (N=30): recently-admitted residents Record Review MDS Sample: assessments from prior 180 days University of Colorado Anschutz Medical Campus 7

QCLIs Quality of Care and Quality of Life Indictors Examples of QCLIs: Underweight and

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 8

Thresholds Rates – threshold = 10% (example rate) For a census sample of 40,

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 9

Simplified QCLI Threshold Analysis Survey QCLI Rate Cited? 19% 1 20% N 2 20%

Simplified QCLI Threshold Analysis Survey QCLI Rate Cited? 19% 1 20% N 2 20% N 3 22% N 4 35% N 5 40% Y 6 41% N 7 50% Y 8 70% Y University of Colorado Anschutz Medical Campus If current threshold is 19% 8 – TRIGGERED and 3/8 or 10 3 – CITED 37. 5% citation rate

Simplified QCLI Threshold Analysis Survey QCLI Rate Cited? 19% 1 20% N 2 20%

Simplified QCLI Threshold Analysis Survey QCLI Rate Cited? 19% 1 20% N 2 20% N 3 22% N 4 35% N 5 40% Y 6 41% N 7 50% Y 8 70% Y University of Colorado Anschutz Medical Campus If current threshold is 37% 4 – TRIGGERED and 3/4 or 11 3 – CITED 75. 0% citation rate

Simplified QCLI Threshold Analysis Survey QCLI Rate Cited? 19% 1 20% N 2 20%

Simplified QCLI Threshold Analysis Survey QCLI Rate Cited? 19% 1 20% N 2 20% N 3 22% N 4 35% N 5 40% Y 6 41% N 7 50% Y 8 70% Y If current threshold is 45% 2 – TRIGGERED and 2/2 or University of Colorado Anschutz Medical Campus 12 2 – CITED 100. 0% citation rate

Small/Not Small Sample Thresholds Census Sample Small: 35 or fewer residents Not Small: 36

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 13

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

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 14

QIS Surveyor Training After SMQT Extensive Classroom training (computer basics, QIS process and software)

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 15

QIS Implementation University of Colorado Anschutz Medical Campus 16

QIS Implementation University of Colorado Anschutz Medical Campus 16

QIS in Indiana First surveys conducted in January, 2011 As of 7/17/2012— 212 QIS

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 17

Triggered Care Areas National and Indiana rates are similar for the following: Frequently Triggered

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 18

Triggered Care Areas cont’d Indiana is a low outlier (compared to National QIS rates)

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 19

Source of “Negative” Responses Indiana QIS rates for: Resident Observation 5% Resident Interview 7%

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 20

Citation Rates for Mandatory Facility Tasks Liability Notices Dining Infection Control Kitchen QA &

Citation Rates for Mandatory Facility Tasks Liability Notices Dining Infection Control Kitchen QA & A Resident Council Med. Admin Med Storage Unnecessary Med Use University of Colorado Anschutz Medical Campus 25% (↑than Nat’l QIS) 23% 46% (↑than Nat’l QIS) 27% 13% (↑than Nat’l QIS) 13% 22% 39% 21

Citation Rates for Non-Mandatory Facility Tasks Abuse Prohibition Adm, Tfr, DC Environment Personal Funds

Citation Rates for Non-Mandatory Facility Tasks Abuse Prohibition Adm, Tfr, DC Environment Personal Funds Sufficient Nursing Staff Extended Survey 23% 22% 74% 26% 13% 60% Rates = # cited divided by # investigated (not total # of surveys) University of Colorado Anschutz Medical Campus 22

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

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 23

Scope and Severity Percentage of F-tags at each S/S level for Indiana QIS very

Scope and Severity Percentage of F-tags at each S/S level for Indiana QIS very similar to Nat’l QIS, slightly higher percentages at A & B A B C D E F G H–L IN QIS University of Colorado Anschutz Medical Campus Nat’l QIS 3. 6% 4. 8% 3. 9% 64. 3% 17. 6% 3. 2% 2. 5% 0. 2% 1. 2% 2. 7% 3. 0% 65. 3% 19. 9% 4. 8% 2. 4% 0. 55% 24

Most Frequently Cited F-tags Nationally in QIS states F 441 Infection Control -- 34.

Most Frequently Cited F-tags Nationally in QIS states F 441 Infection Control -- 34. 9% F 329 Drug Regimen free from Unecc. Drugs -- 34. 1% F 323 Free of Accident Hazards -- 31. 3% Indiana QIS F 282 Srvcs by Qualified Persons per Care Plan -- 44. 7% F 323 Free of Accident Hazards -- 41. 6% F 279 Develop Comp. Care Plans -- 41. 1% University of Colorado Anschutz Medical Campus 25

Citation Rates for Selected F-tags F 282 Nat’l QIS IN QIS diff 21. 1%

Citation Rates for Selected F-tags F 282 Nat’l QIS IN QIS diff 21. 1% 44. 7% -23. 6% 12. 1% 28. 9% -16. 9% 19. 5% 32. 0% -12. 5% (Svcs by Qual. Pers per CP) F 156 (Notice of Rights) F 253 (Housekeeping) University of Colorado Anschutz Medical Campus 26

Citation Rates for Selected F-tags F 280 (Right to particp. In CP) Nat’l QIS

Citation Rates for Selected F-tags F 280 (Right to particp. In CP) Nat’l QIS 27. 8% IN QIS 22. 3% diff 5. 5% F 281 9. 9% 4. 1% 5. 8% F 272 24. 4% 17. 8% 6. 5% (Srvcs. meet Professional Stds. ) (Comprehensive Assessments) University of Colorado Anschutz Medical Campus 27

Citation Rates for Selected F-tags Nat’l QIS IN QIS F 492 3. 2% 0%

Citation Rates for Selected F-tags Nat’l QIS IN QIS F 492 3. 2% 0% F 274 1. 6% 0% F 497 1. 2% 0% (Comply w/Fed/St/Local Laws/Prof. Stds. ) (Comp. Assess. After Sig Change) (Nurse Aide Perform Rev-12 hr/yr in-service) University of Colorado Anschutz Medical Campus 28

Citations and Survey Time Nat’l QIS IN QIS Average Number of Citations per Survey

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 29

Contact Information University of Colorado QIS website http: //www. ucdenver. edu/academics/colleges/medicalsch ool/departments/medicine/hcpr/qis/Pages/default. aspx CMS

Contact Information University of Colorado QIS website http: //www. ucdenver. edu/academics/colleges/medicalsch ool/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 30

Questions? Martha Powell Martha. Powell@ucdenver. edu (303) 724 -2434 Sayuri Kelly Sayuri. Kelly@ucdenver. edu

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 31