The Quality Indicator Survey Process (QIS) Care Providers of Minnesota Board of Directors Meeting March 15, 2007

QIS Developed by the University of Colorado, University of Wisconsin (CHSRA), Maverick Systems, and Alpine Technologies under contact with Research Triangle. Developed from , refinements since.

Pilots to-date Piloted in 5 states between October 2005 and October 2006: –California –Connecticut –Kansas –Louisiana –Ohio Conducted over 170 QIS surveys for evaluation

Expansion of Pilots In December 2006 CMS sent out a solicitation to all non-pilot states informing them of the expansion of the QIS pilot. No specific number of additional states identified CMS estimates expansion into the expanded states would commence in the fall of 2007 MDH has applied for inclusion in the expansion The MDH application was supported by Care Providers of Minnesotas Regulatory Committee and Executive Management Committee.

What is the QIS? A different, more automated, data driven method to survey for compliance with Federal Regulations. QIS Objectives: 1.Improve the consistency and accuracy of surveys using a structured process 2.Comprehensively survey all regulations 3.Enhance documentation through automation 4.Focus survey resources on facilities with the largest umber of quality concerns 5.Do it all within existing survey and certification budgeted resources

Facility TourOffsite PreparationEntrance Conference Stage 1 Sample Selection (3 Samples: MDS based, Admission, Census Stage 1 Sample Review (Resident, Family, & Staff interviews, Resident Observations, Medical Record Reviews) Facility-Level InvestigationsStage II InvestigationMedication Adm Observation Identify care deficiencies and determine S/S of deficiencies Exit Conference

How Does the QIS Work? Offsite Survey Preparation –Review of facility history, complaints, and ombudsman reports (nothing new here) –Surveyors pre-load all facility MDSs into their computers (new) –No review of QMs, QIs, or OSCAR reports to pre-select a resident sample (new)

Entrance Conference Roster/Sample Matrix (CMS 802) no longer required Must provide resident census in alphabetical order (incl room #s and units) Must provide closed admission records within one hour

Tour Brief overview of the facility Used to get a sense of the facility and residents Not intended to augment the resident sample or to begin investigations

Stage 1 Samples MDS Sample – includes all residents with an MDS assessment within the past 6 months Census Sample – Random sample of 40 current residents Admission Sample – Random sample of 30 recent admissions Surveyor Sample – Initiated sample at surveyors discretion

Advantages of Stage 1 Samples MDS Sample – covers all residents (except very recent) but is only facility- reported information Census Sample – emphasizes long-stay residents because it is cross- sectional…primary observation information Random Admission Sample – captures post-acute admissions

Resident Interviews Surveyors will use the Cognitive Performance Scale (CPS) from the downloaded MDS data to calculate which residents are interviewable: –CPS Score 1-3: Interviewable –CPS Score 4-7: Family Interview Candidate If resident has no MDS they will be listed as interviewable until otherwise determined

Resident Interviews General Questions… –Are you from here? Tell me about yourself? How long have you been here? What food do you like here?, etc. Required Structured Questions… –Choices, Dignity, Activities, Building & Environment, Participation in Care Plan, Abuse, Interaction with others, Personal property, Pain, ADL assistance, Food quality, Hydration, Sufficient staff, Privacy, Exercise of rights, Personal funds.

Resident Observations Cleanliness, Grooming, Oral health, Incontinence, Dressing, Activities, Contractures, Abuse, Skin, Restraints, Pain, Hydration, Positioning, Accident hazards, Siderails, Resident room condition.

Overall Facility-Level Investigations Tasks completed on every survey: –Resident Council representative interview (no more group interview) –Dining observation –Kitchen/Food Services observation –Infection control –Demand billing –Quality Assessment and Assurance review

Overall Facility-Level Investigations Tasks if triggered by Stage 1 Findings (resident/family/staff interviews, resident observations, & medical record reviews) –Abuse Prohibition review –Admission, Transfer, & Discharge review –Environment –Resident Funds –Sufficient Staff

Then Everything Gets Dumped into One Computer Each surveyor downloads documentation from their tablet computers onto a flash drive and combines all surveyor data onto the Team Leaders computer.

Data Driven The QIS Data Collection Tool (DCT) calculates the Quality Care Indicators (QCIs) There are a total of 160 QCIs and Facility level tasks: –44 MDS (includes the 24 quality indicators) –68 Census – 6 Administration –42 Facility

Data Driven The facility-specific QCIs are calculated and compared to national rates If the rates exceed the established thresholds, and in-depth investigation of those care areas is conducted (State II) Stage II resident samples are selected by system software State II investigation is required to determine if there are deficient practices

Stage II Evaluate Care Practices in relation to Stage I findings Resident-level and facility-wide Medication Administration Observation Use of Critical Element Pathways to structure the investigative process (Activities, ADLs, ROM, Behavior, B&B, Communication, Dental, Dialysis, Hospitalization, Death, Nutrition, Hydration, Tube Feeding, Pain, Restraints, Pressure Ulcers, Medications, Rehab and Community discharges, Vents) Integrates information from multiple data sources Rate severity for each resident where deficient practice is found

Surveyor Team Meeting Discuss: Staff-to-resident interactions, availability of staff and staffing patterns, activities observed, characteristics of resident population, meal times, scheduled activities, and medication pass times, residents with unmet needs. Surveyors will be assigned to observe various meal times in dining areas and resident rooms if deemed appropriate.

Regulatory Determination Combine Stage II findings across residents by F-Tag Integrates survey team findings into a single statement Uses documentation from Stage I and Stage II findings Identifies deficiencies and determines scope and severity Exit Conference

Facility TourOffsite PreparationEntrance Conference Stage 1 Sample Selection (3 Samples: MDS based, Admission, Census Stage 1 Sample Review (Resident, Family, & Staff interviews, Resident Observations, Medical Record Reviews) Facility-Level InvestigationsStage II InvestigationMedication Adm Observation Identify care deficiencies and determine S/S of deficiencies Exit Conference

QIS Process Strengths Larger Sample Sizes – it requires a sample of adequate size to infer anything about the population…plus different samples are used (admission, census, mds, etc.) Comprehensive – past studies have demonstrated that some surveyors focused only on select deficiencies – Structured approach requires surveyors to examine all regulations

QIS Process Strengths Structured Approach – Systematic observations and questions are comparable across all sites and are replicable…providers could potentially also used the tools to improve regulatory compliance Enhanced Documentation – Information collected throughout the process is collated by computers for development of the 2567…Trail of findings available to follow on-site decision- making

Questions?