Are You Ready for the New Survey

There is a transformation under way of the long-term care (LTC) survey process, and it has significant implications for every LTC facility in the nation. The Quality Indicator Survey, or QIS, is being developed under the auspices of the Centers for Medicare & Medicaid Services (CMS) and is in the final stages of a demonstration project.

Based on a two-stage quality assessment approach first developed at the University of Colorado in 1993, the QIS has experienced years of pilot testing and evaluation in three phases in seven states. According to CMS, testing and evaluation continued through September 2008, along with the development of training materials and a national training approach, and the QIS will be ready for national rollout beginning late in 2008.

The goal of QIS is simple: through a more structured survey process, to improve the consistency and accuracy of care and quality of life problem identification for LTC residents. The QIS surveyors will achieve this through: (1) a systematic review and objective investigation of all triggered regulatory areas within current survey resources, (2) enhancing documentation through automation, and (3) concentrating survey resources on facilities with the largest number of quality concerns.1

Those LTC facilities in one of the states involved in the pilot project or preparing for national rollout are already aware of the impact of QIS. The QIS system has been implemented statewide in Connecticut, while Florida, Louisiana, Kansas, Ohio, and Minnesota are rolling it out this year. This past summer, North Carolina, New Mexico, and West Virginia began implementation.

What is QIS? You could say that QIS is MDS (Minimum Data Set) on steroids. The new survey process will undoubtedly challenge those LTC facilities that have had difficulty improving the accuracy of their MDS database. My recommendation to LTC facilities is to tackle improving the accuracy of their MDS data now. Don’t wait—QIS is coming; it represents a new paradigm in the assessment of care and quality-of-life indicators in LTC facilities, and steps should be taken now to improve the accuracy of MDS data or risk F-tag citations and the public image and business challenges they bring.

If QIS represents a new assessment system, then why will the MDS data be important? Because the foundation of the more structured and objective QIS assessment process is the MDS database and, during the pre-site visit stage of the survey process, reviewers will have at their disposal larger samples of residents based on validated MDS data.

Quality-of-Care Indicators continue to be an important part of the survey process. In fact, the QIS methodology utilizes 162 Quality of Care Indicators—far more than those comprising the MDS. The QIS also focuses on resident, family, and staff interviews, prior deficiencies, complaints, and existing waivers and variances. The QIS methodology establishes a threshold for each facility for particular Care Areas, based on specified national benchmarks, allowing that a certain number of those occurrences could be normal. When a facility’s MDS database exceeds the threshold for a particular area, it will likely prompt surveyors to pay close attention to that area during the survey process.

More robust

The pre-site visit phase of the assessment is much more robust. First, the survey team will review a larger sample of residents and MDS data from each facility. Information for all residents who had an MDS assessment at any time during the prior six months will be uploaded to the survey team’s tablet PCs. With the pre-site visit work behind them, the surveyors will bring extensive information about the facility to the initial visit. They will already know which Care Areas, or Critical Element Pathways, they plan to focus on during the assessment.

The start of the site visit initiates Stage I of the assessment. During this stage, surveyors complete staff, resident, and family interviews; observe residents; and complete reviews of clinical records. At the same time, various facility-level investigations focus on food preparation areas, dining rooms, infection control practices, quality assessment and assurance, and similar areas.

Throughout the process, the surveyors’ observations are entered directly into the QIS Data Collection Tool (DCT) tablet PC on special CMS forms. Gone are the mountains of notes and paperwork associated with the current assessment process—the QIS process is completely digital. (CMS forms for each of the Critical Element Pathways, as well as mandatory and triggered facility-level tasks and other electronic forms and worksheets, are available for review on the University of Colorado at Denver Health and Sciences Center Web site at

Upon completion of Stage I, the survey team uses the data gathered, plus the facility’s own MDS data, to create resident-centered outcome and process indicators. Called Quality of Care Indicators, these denote those areas that will require further evaluation and assessment during Stage II. Investigations at the facility level will also take place in Stage II, focusing on such areas as billing, infection control, food service, and quality assessment and assurance. Further investigation into certain Care Areas, such as abuse, environmental observation, and personal funds review, is required only if they were triggered during Stage I.

New level of surveying

The surveyors use special protocols that guide them through the investigation to help determine if the facility is in compliance. The process is highly objective; there are no “gray” areas. The facility either meets the critical elements of care, or it does not. Furthermore, the QIS protocol alerts the surveyor to possible F-tags for citation and requires documentation and an assignment of severity level (see the CMS forms referenced above).

After all of the investigations have been completed, the survey team assesses the results to determine if the facility is deficient in any areas. This information is then presented to representatives of the facility during an exit conference.

It should be apparent that the new QIS takes the LTC survey and assessment process to an entirely new level. The fact is, few LTC facilities outside of the states involved in the pilot project are prepared for this new, structured process. There are, however, practical steps that every LTC provider can take—starting today—to help prepare their facilities, staff, residents, and family members for QIS:

  1. Start now to prepare the facility and all of its stakeholders for the new QIS process. View QIS as an opportunity to transform the quality assurance program at the facility and recognize that everyone—administrators, staff, residents, and family members—has a role to play.

  2. Create a team to oversee the project. This task touches every corner of the facility. Identify representatives from key clinical and support areas that have the knowledge of the new survey process and the leadership skills to inspire and help the organization reach its goal.

  3. Obtain the QIS survey materials from CMS or another published resource, then utilize the tools that are a part of the QIS to build a comprehensive program. The QIS assessment tools provide important resources for implementing a facility-wide program.

  4. Drive up accuracy of your facility’s MDS data. How accurate is your MDS database now? You need to achieve the highest level of accuracy possible! Why? Although QIS represents a new paradigm for the LTC industry, MDS data represent essential inputs into the new process. A facility that is struggling with MDS accuracy will not fare well under QIS.

    Documentation that relies on recall (like a keystroke technology) also puts you at risk. So it’s important to document as close to point-of-care as possible. From everything I’ve seen to date, nothing is closer to the point-of-care than voice-assisted care. If you haven’t seen it yet, it’s worth a look.

  5. Set the bar high. Using the QIS survey tools, determine the facility’s degree of noncompliance, establish goals for improvement, then measure outcomes.

  6. Get appropriate training and education. Preparing for QIS requires its own systematic approach. Seek out the support of credible professionals who are experienced with QIS to assist your staff, residents, and families to respond appropriately to the questions in the new survey process.

  7. Improve communications with staff. A comprehensive training program will demonstrate to staff that they represent a key component of a successful quality assurance program based on QIS. At the same time, a training program creates the all-important “buy-in” that will be critical to a successful review.

  8. Empower residents and families. The QIS survey relies heavily on resident and family interviews. This gives the residents and families a larger voice in the process but, where resident and family empowerment and communications has not been fostered, the survey will give them plenty of opportunity to express their dissatisfaction.

  9. Practice and prepare. As with everything, practice makes perfect. The new quality assurance program based on the QIS will create many opportunities for practice and refinement.

  10. Celebrate your accomplishments! Facilities should make sure that they take time along the way to acknowledge the efforts of all involved, and following a successful assessment, celebrate!

Leah Klusch is the Founder and the Executive Director of the Alliance Training Center. As an educator and consultant, she has extensive experience in presenting motivating programs for a variety of healthcare professionals.

For further information, call The Alliance Training Center, Inc., at (800) 890-5526 or (330) 821-7616. To send your comments to the author and editors, e-mail


  1. CMS Quality Indicator Survey Demonstration Project, April 2007. Available at:

Long-Term Living 2008 December;57(12):18-21

Topics: Articles , Regulatory Compliance