Transitioning to QIS

Transitioning to the Quality Indicator Survey (QIS) protocol can be a smooth passage when facility leaders introduce the tools and process to their team through an organized implementation plan and training. The QIS tools, in reality, are designed to give voice to residents, and facility team members who take them seriously soon realize their use results in maximized clinical outcomes and improved quality of life.

Implementation of the QIS has been progressing state by state since 2009, and nursing home teams where it has been implemented have made the transition-some easily and others with a struggle. Those who have prepared well in advance for the change from Traditional to QIS have found that the QIS protocol keeps surveyors focused on designated tasks and gives the facility opportunity to identify and correct concerns prior to surveyor arrival. Many refinements were implemented in January 2011 that improved the focus on the resident as the center of all survey activity. Whether a particular state is just coming on board or is scheduled for a future date, a detailed look at the QIS process will reveal an incredibly organized set of tools that, when used in a Quality Improvement effort, will reveal each home’s weaknesses and strengths, and enable a course to be plotted for delivering quality care as never before.

To understand the transition from the Traditional Survey to the automated QIS process, it is helpful to compare key activity for the two versions. Table 1 displays similarities and differences at a glance.

Table 1. Traditional vs QIS Survey1

The Traditional Survey and the QIS each follow a series of prescribed tasks. There are seven tasks used by a survey team to complete a Traditional Survey and nine for QIS.2 The additional categories for QIS result from revised activity using an automated computerized system into which surveyors enter information while completing their observations and data collection. The software version now in use is ASE-Q (ASPEN Survey Explorer for Quality Indicator Surveys), which replaced the original QIS-DCT (Data Collection Tool) on November 1, 2010.1

The Traditional Survey incorporates two phases, as noted in Table 1. QIS has two stages designed to guide surveyors through objective investigations of regulatory areas that are triggered as they enter data into tablet personal computers. The process begins offsite with review of prior deficiencies, current complaints, ombudsman information, existing waivers and MDS information. Upon arrival at a facility, surveyor activity includes an entrance conference held by the team leader with the administrator and a concurrent brief tour by the rest of the team to gain an overall impression of the facility and residents. Requested forms that are unique to QIS include an “Alphabetical Resident Census” and a “New Admission Information” form listing all new admissions within the prior 30 days. The Traditional Survey sample size was based on the number of beds in the facility, but QIS uses up to 40 randomly selected current residents, up to 30 recent admissions (some may have been discharged, so closed chart review is conducted), and draws from MDS data to create a resident pool.1

The most valuable change for nursing facilities is the availability of investigative tools used by the survey team that can be downloaded and incorporated into a powerful Quality Improvement program. Review of the CMS forms listed in Table 2 will acquaint any administrative team member with QIS survey-specific activity. Using these forms to collect data, analyzing results and developing corrective action plans can fully prepare any facility for survey. The Table 2 forms were revised and re-released in January 2011, many with adjusted thresholds based on information learned to date about QIS outcomes.

Table 2. QIS Forms

QIS Stage 1 Forms

  • Census Sample Record Review

  • Family Interview

  • Resident Interview & Resident Observation

  • Staff Interview

QIS Stage 2 Forms-Critical Element (CE) Pathways

  • CE for Activities

  • CE for ADLs and/or Range of Motion

  • CE for Behavioral and Emotional Status

  • CE for Urinary Incontinence, Urinary Catheter, UTI

  • CE for Communication and Sensory Problems (includes hearing and vision)

  • CE for Dental Status and Services

  • CE for Resident Who Receives Dialysis Treatments

  • General CE Pathway (used for quality of care concerns not otherwise covered)

  • CE for Hospice and/or Palliative Care

  • CE for Hospitalization or Death

  • CE for Pain Recognition and Management

  • CE for Use of Physical Restraints

  • CE for Pressure Ulcers

  • CE for Psychoactive Medications

  • CE for Rehabilitation and Community Discharge

  • CE for Ventilator-Dependent Residents

  • CE for Unnecessary Medication Review

  • CE for Preadmission Screening and Resident Review

  • CE for Hydration Status

  • CE for Tube Feeding Status

QIS Mandatory Facility Task Forms

  • Liability Notices & Beneficiary Appeal Rights Review

  • Dining Observation

  • Infection Control & Immunizations

  • Kitchen/Food Service Observations

  • Medication Administration Observation

  • Resident Council President/Representative Interview

  • Quality Assessment and Assurance Review

  • Medication Storage

QIS-Triggered Facility Task forms

  • Abuse Prohibition Review

  • Admission, Transfer and Discharge Review

  • Environmental Observations

  • Sufficient Nursing Staff Review

  • Personal Funds Review

  • QIS Extended Survey

A visit to will enable downloading of all QIS forms and other valuable information. By using the interview tools and Critical Element Pathways, a nursing home team can implement the care area investigative protocols that guide surveyors in completing their reviews. Each care area has its own threshold designed to trigger investigation when frequency surpasses the CMS-determined acceptable level.

Initially, QIS was viewed by many as overwhelming, when in reality it is a focused process with tools specifically designed to uncover quality of care and quality of life concerns. That task should not be left solely to the state survey teams-it is the responsibility of every facility administrative team. By taking the QIS tools seriously and utilizing them for QA activities, the transition from the Traditional Survey to the new QIS format will be smooth and resident care will be improved.

To view a complete listing of QIS implementation dates, visit and click on QIS Implementation Schedule, under the heading “Resources.”

Betty MacLaughlin Frandsen RN, NHA, MHA, C-NE, has worked in long-term care for more than 30 years, including 14 years as a director of nursing, and as an administrator in both Pennsylvania and New York. She served as vice president of Education and Regulatory Affairs for AANAC, and is a past president of NADONA/LTC. You can reach her at


  1. CMS Quality Indicator Survey/ASE-Q (April 2011). Available at:
  2. State Operations Manual: Appendix P (04/24/09). Available at:

Long-Term Living 2011 October;60(10):44-46

Topics: Articles