1. State Performance Standards System
Bonnie Reed
Dominick Esposito
August 5, 2019

2. Introduction Motivation for revising the SPSS
A multi-stakeholder effort
What the future holds…

3. Agenda
SPSS transformative changes and what it means for State Agencies
SPSS redesign schedule in FY2020
State Performance Indicators
Input and feedback from you!
State-specific Measures
Questions and comments

4. Thank you for your feedback!
44 States
70+ Questionnaires
60+ Conversations
Hundreds of s
More than 500 pages of notes to review!

5. SPSS Transformative Changes
Based on input from all SPSS stakeholders to improve SPSS consistency, relevancy, and effectiveness in service of improved quality of care for Medicare clients

6. Transitioning to a Quality Management System
Transform the SPSS into a quality management system to help ROs and SAs identify potential areas of concern quickly, address state-specific concern areas, and improve SA performance/maintain high SA performance over time
SPSS Transformations
Data-driven. Establish quarterly extract of Frequency measures, scoring measures, and other performance indicators (e.g., SOAR reports) to help ROs and SAs act faster
Consistency. Reduce subjectivity by refining evaluation criteria and methods of evaluation for some measures.
State-specific. Add components to the SPSS that address areas of concern for individual SAs.
Focused resources. Encourage strong SA performance and investigation of concern areas with a “year off” for some measures once new SPSS is off-the-ground to turn attention to potential areas of concern.

7. SPSS Transformative Changes
State Performance Indicators
State-specific measure
SPSS Quality Domain
Quarterly Frequency Data

8. State Performance Indicators
Metrics that use SA survey data and other sources
CMS to construct/distribute to ROs and SAs
Quarterly reports/dashboard in a standard format
Provide information on where SA stands relative to national average/median as well as peer group
ROs and SAs collaborate to proactively identify potential areas of concern
Encourage ongoing discussion on data-driven indicators
Assess performance in real-time; links to metrics in SOAR reports for LTC survey process
Phased roll out process including SA feedback today

9. State-specific Measure
New, scored measure focused on making improvement in States’ potential areas of concern
State Performance Indicators are first-line candidates for a State-specific measure
Already constructed for ROs and SAs and relevant to performance
Other agreed upon measures may also be relevant
A State-specific measure may not be necessary for all SAs in every year
Encourage improved quality management over time
Phased roll out process including SA feedback today

10. SPSS Quality Domain
Improving consistency, reducing subjectivity, and encouraging improvement in SA performance

11. SPSS Quality Domain
Revised the documentation of deficiencies (Q1) to improve consistency, reduce subjectivity, and reduce burden
RO review committee approach established to improve consistency across regions
Revised language to make criteria less subjective
Reduced the number of criteria to reduce burden
June 2019 – pilot of revised Q1 criteria, and revised processes for both Q1 and Q6.

12. Revised Q1 Criteria
There is sufficient evidence on the CMS-2567 to support a citation
The appropriate regulation was cited based on the evidence provided on the CMS-2567
Nursing homes only: There is sufficient evidence to support the assigned severity rating as documented on the CMS-2567
Nursing homes only: The scope rating of the citation accurately reflects the number of residents who are, or may be, affected by the deficient practice as documented on the CMS-2567
Non-nursing homes only: The level of citation (Condition, Standard, or Element level) accurately reflects the evidence presented as documented on the CMS-2567

13. Other Changes in the Quality Domain
Global changes in the Quality Domain
Review less frequently if SA performs well consistently and SPSS is implemented successfully
Increase sample size for review if SA does not perform well.
This will minimize small sample bias and identify potential areas of concern
Quality measure
Changes
Q2-Q3. FOSS measures (LTC)
Updated to reflect the new FOSS process
Q4. Comparative LTC Surveys
Updated to include more than 1 year of data
Q6 through Q8.
No change
Q9. Quality of Intake Surveys
Considering changes to better understand the process of intake survey work by SAs
Q10. State-specific measure
New measure in FY2020

14. Quarterly Frequency Dashboard

15. Quarterly Frequency Dashboard
Possible display of Frequency measure run rates for a Region to review.
Same view provided for each SPSS Frequency measure.
Can be created directly from existing data.
Allows States to see whether they are falling behind
SAs and ROs have time to act before year end
Accessible in Excel
SAs receive their own data for review
ROs receive data for each of their States
Considering visuals to summarize frequency data

16. Quarterly Frequency Dashboard
Stop here - Ask conference attendees for feedback on quarterly frequency data. Tell them they can write any additional feedback on the back of the handouts on the table.

17. State-level Frequency Reports
Summary by Provider Type for Surveys and Timeliness

18. State Performance Indicators
A step towards becoming more data-driven

19. Why State Performance Indicators?
Identify potential areas of concern proactively
Encourage ongoing communication between ROs and SAs on data-driven indicators
Understand SA performance in real-time
Link to metrics in SOAR reports for LTC survey process; similar metrics for NLTC

20. What are State Performance Indicators?
Metrics based on SA survey data and other sources
Quality Domain
Standard Surveys
Intake Surveys
Coordination of Provider Noncompliance (i.e. Enforcement)
Resource Management
CMS to create reports for SAs and ROs quarterly in a standard, user-friendly format
Information on where SA stands relative to national average, median, and peer group
Summaries across all domains, indicators, and providers

21. State Performance Indicators
Example metrics for Intakes:
Intakes per provider by facility census
Allegation rate by facility census
Allegation reoccurrence rate
Intake prioritization distribution
Allegation citation rate
Outlier values do not automatically imply there is a problem
further investigation and discussion may be needed
Data provides opportunity to encourage collaboration and identify potential areas of concern that SAs and ROs might overlook
Intake – called to complain. That is one intake. How many contacts to the State (phone calls, letters, s)
Allegations – called to give 5 different complaints. That is an allegation (how many things have they brought to our attention to look at).
Allegation “citation” rate instead of substantiation rate, because substantiation data has a lot of data entry errors

22. State Performance Indicator Report

23. Time to get interactive!
State Performance Indicators
Exercise: Review the State performance indicator report mock-up
Is this format helpful?
Are there potential indicators that you might also want to see or that you use in your State?
Other discussion questions:
What do you like?
What is missing?
Report out
Nominate a group member to share your thoughts

24. State-specific Measure
Encourage investigation of potential concern areas to improve State performance

25. State-specific Measure
Scored measure focused on making improvement in States’ potential areas of concern
Investigate potential areas of concern for root causes
Develop plan for improvement
Establish and measure improvement goals
Pilot and assess usefulness, relevance, and value in FY2020
A State-specific measure may not be necessary in all States in every year
State Performance Indicators are first-line candidates for a State-specific measure
Already constructed for ROs and SAs and relevant to performance
Other agreed upon measures may also be relevant

26. State-specific Measures
Improve State performance in service of higher quality care

27. Example: State-specific measure
Area of concern: Citation rates among intake allegations are consistently lower than median nationally and lean towards lowest among all States
Performance Improvement Plan
Actionable objective: State the goal of the activity to be conducted
Measurable outcome: Citation rate among intake allegations
Action Plan: Document the actions taken to carry out the performance improvement plan
RO responsible for two-pronged assessment
Reviews actions taken by the SA to implement plan
Reviews measurable outcome to determine progress
The purpose of these examples is to illustrate ways SAs and ROs could use State Performance Indicators to identify an area of concern and implement a Performance Improvement Plan. Each example provide the following:
Identifies a problem area using a state performance indicator then shows how States could explore root causes of the problem
Discusses how States could use this information to develop a plan for performance improvement and potential components of this plan
Discusses the importance of monitoring the impact of performance improvement plans and show how States could use various measures for evaluation and assessment of the performance improvement plan

28. Time to get interactive!
State-specific Measure
Exercise: Your SA team seeks to work with your RO on an agreed upon area of concern
Do the materials/templates provided help guide you on next steps with your RO?
What is missing that would be helpful to you and your team?
Other discussion questions:
Thoughts on the format of the materials:
What do you like? What is missing?
Will the process help take a step towards SPSS as a quality management system?
Report out
Build off what they already saw.
Give them a template for what they will have to fill out
Choose an indicator where there is an outlier
Talk through what you would discuss with regions whether it is outlier or if there is a good reason for it
Does guidance help
How would you move forward to move the needle on that indicator? That is your process
Does this work.
Pitfalls beyond burden and time.

29. Questions and Comments
Are we moving in the right direction?
Direct line to the project team with any questions or comments: