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.
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 http://www.uchsc.edu/hcpr/qis_forms.php.)
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.