1. QIS Information to Support States Preparing for QIS Training and Implementation 1

2. Agenda  Welcome and Introductions  Background and Overview of QIS  QIS – Continuous Quality Improvement  State Roles and Responsibilities in Training Process  Description and Timing of QIS Training  Questions 2

3. 3 What is the QIS?  Approved Federal nursing home survey process to increase consistency, reliability and accuracy  Uses customized software on tablet PCs to guide surveyors through a two- staged systematic review of the regulatory requirements

4. 4 QIS Development  Produce prototype (1998 – 2005)  Demonstration and Evaluation (2005 – 2007) –Two teams each in: KS, OH, CA, CT, LA  Develop and refine national training model (2006 2007) –Three States: FL, CT, KS  National implementation State-by-State to replace Traditional survey (2007 – present)

5. What Does the QIS Provide?  Structured approach to achieve more accurate and consistent results  Larger and more diverse randomly selected samples to obtain a more accurate picture of the residents  Automation to systematically review regulatory areas, synthesize surveyor findings, enhance investigative protocols, and organize surveyor documentation 5

6. What QIS Is Not QIS Does Not Represent:  Change in Social Security Act  Change in the Regulations  Change in Interpretive Guidance  Change in enforcement process 6

7. Comparison of QIS and Traditional Survey Process 7

8. Automation Traditional Information recorded on paper throughout process; computers are used for Statement of Deficiencies (CMS- 2567) QIS Each team member uses a tablet PC to document findings throughout the process; findings are synthesized, organized, and loaded to the CMS- 2567 by the software 8

9. Offsite Preparation Traditional  Review:  OSCAR 3 and 4 Reports  QM/QI Reports  Results of complaint investigations  Pre-select a sample based on above QIS  Review:  OSCAR 3 Report  Uninvestigated complaints  Random selection of Stage 1 samples from MDS data loaded onto tablet PCs 9

10. Onsite Preparation Traditional  Roster/Sample Matrix – Form CMS-802 QIS  Alphabetical resident census with room numbers/units  List of new admissions over last 30 days 10

11. Initial Tour Traditional  Gather information about pre-selected residents and identify new concerns  Determine whether pre-selected residents are still appropriate QIS  Brief overall impression of the facility, the residents, and the staff  Not intended for sample selection or supplementation 11

12. Sample Selection Traditional  Sample size determined by facility census  Residents selected based on QM/QI percentiles and issues identified offsite and on the initial tour QIS  Stage 1 sample size: Admission (30) Census (40)  Stage 2 sample size based on number of triggered care areas  Residents selected by software  Surveyor-initiated sample 12

13. Survey Structure Traditional  Phase I: focused & comprehensive reviews  Phase II: focused reviews QIS  Stage 1: preliminary investigation  Stage 2: in-depth investigation of triggered concerns from Stage 1 13

14. 14 Two Stages of QIS Stage 1: Preliminary investigation of regulatory areas to determine resident care areas and facility practices for Stage 2 investigation Stage 2: In-depth investigation to determine whether deficient practice exists, document deficiencies, and determine severity and scope

15. 15 Three Steps in Each Stage 1.Sampling (computer-generated) 2.Investigation 3.Synthesis

16. 16 QIS Stage 1  Sampling – Random census (40) and admission (30) samples  Investigation – Structured resident, family, and staff interviews; resident observations; chart reviews  Synthesis – 128 resident-centered and 34 facility-level Quality of Care and Quality of Life Indicators (QCLIs) to identify care areas that exceed national thresholds

17. 17 Stage 1 Triggers for Stage 2 Investigations

18. 18 Surveyor-Initiated Sample Surveyors can initiate an investigation of care areas for any resident or of facility tasks. Because of the large QIS samples, surveyor-initiated investigations are a small part of the process.

19. 19 QIS Facility Tasks  Completed on every survey – Liability Notices & Beneficiary Appeal Rights Review – Dining Observations – Infection Control and Immunizations – Kitchen/Food Services – Medication Administration and Drug Storage – QAA – Resident Council President Interview  Completed if triggered – Abuse Prohibition Review – Admission, Transfer, and Discharge Review – Environmental Observations – Personal Funds Review – Sufficient Nursing Staff Review

20. 20 QIS Stage 2  Sampling – Three residents per triggered Care Area plus surveyor-initiated residents (e.g., complaints)  Investigation – Specific or general Critical Element pathway or facility task pathway and interpretive guidelines  Synthesis – Determine compliance with each Critical Element, document noncompliance at the applicable F tags, determine severity and scope

21. QIS Satellite Broadcast: http://surveyortraining.cms.hhs.gov/pubs/VideoInformati on.aspx?cid=1082 QIS Resource Manual: http://www.uchsc.edu/hcpr/qis_manual.php QIS Electronic Forms and Worksheets: http://www.uchsc.edu/hcpr/qis_forms.php QIS Brochure: http://www.cms.gov/SurveyCertificationGenInfo/downlo ads/SCLetter08-21.pdf http://surveyortraining.cms.hhs.gov/pubs/VideoInformati on.aspx?cid=1082 http://www.uchsc.edu/hcpr/qis_manual.php http://www.uchsc.edu/hcpr/qis_forms.php http://www.cms.gov/SurveyCertificationGenInfo/downlo ads/SCLetter08-21.pdf 21 Additional Information

22. QIS – Quality Improvement CMS-Federal Monitoring of the QIS  RO surveyors trained in QIS process  Desk Audit Reports  DAR-SA for State  DAR-RO for CMS Regional Office  Federal Oversight of the QIS (FOQIS)  QIS Comparative Survey 22

23. 23 QIS - Quality Improvement Desk Audit Report (DAR) a management tool which can be used by:  The CMS CO for ongoing monitoring of QIS consistency across Regions Offices (RO) and States (SA);  The RO’s for Federal Oversight of the QIS process (FOQIS); and  The SA’s for monitoring districts, teams and individual surveyors

24. RO & SA use of the DAR  Reviews results;  Raises questions;  Investigates outcomes;  Assists the RO & SA with oversight/training; and  Can direct SA monitoring 24

25. 25 Timeline  CU sends 6 DAR-SAs with clinical analysis and a call to discuss each  CU sends 3 DAR-SAs with clinical analysis and no call  SA receives clinical analysis training  CU and SA comparison for one DAR-SA  SA assumes responsibility of analyzing DAR-SAs

26. Goal of QIS Data Identify and address sources of inconsistency:  Implementing the QIS process accurately  Conducting adequate and thorough investigations and making accurate compliance decisions 26

27. DAR-SA Review 1.Throughout each quarter, SA reviews multiple DAR-SAs –Identify and analyze outliers/trends –Determine root cause –Implement training, monitoring or corrective action as appropriate –Monitor effectiveness 27

28. DAR-RO Review 2. At the end of the quarter, RO and SA receives State-Specific DAR-RO 3. RO conducts QI call within 4 weeks (not fully implemented) 4. Onsite FOQIS is conducted using a targeted, data-driven approach (not fully implemented) 28

29. Preparing for Successful QIS Training and Implementation Review CMS Issued Documents  Fiscal Year State Survey & Certification Budget Letter (Mandatory Requirements - equipment and encryption)  State Operations Manual, Appendix P  QIS Training Process - State Operations Manual, Chapter 4  National Implementation Priority Order (S&C 09-50)  QIS Satellite Broadcast: http://surveyortraining.cms.hhs.gov/pubs/VideoInformation.aspx?cid=1 082 http://surveyortraining.cms.hhs.gov/pubs/VideoInformation.aspx?cid=1 082  QIS Brochure: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter0 8-21.pdf http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter0 8-21.pdf 29

30. Preparing for Successful QIS Training and Implementation  Informing State management about QIS  Identifying QIS management and teams  Educating stakeholders in the State  Begin logistics preparation for initial QIS classroom training 30

31. Preparing State Management Team for QIS  Kick off call with State, CMS, and NHQ  Orient and educate managers/supervisors about QIS, the training process and  State develops QIS training plan  Identify a QIS State Lead  Identify a QIS IT Lead  Identify 8 surveyors to participate in initial/core QIS Classroom Training  Identify additional support staff to help with preparatory logistics for QIS training 31

32. Role of QIS State Lead  Able to make supervisory decisions and provide oversight  Support the QIS process  Participate in QIS training, classroom and field  Achieve mastery of the QIS  Manage potential challenges from nursing homes  Serve as the point of contact for the State Agency for discussion with CMS and/or its contractors  Educate provider and consumer organizations  Collaborate in the planning and preparatory activities with the training contractor 32

33. Role of QIS State IT Lead  First line of contact for surveyors to address and resolve software issues using the QIS process and QIS software  Successfully completes ASPEN Technical Training  Experienced and proficient with all ASPEN suite of products  Creating survey shells in ACO  Assisting staff with uploading surveys from ASE to ACO  Participates in both classroom and onsite QIS training  Able to train additional staff on the technical aspects of the QIS process 33

34. QIS Core Group of Surveyors  State identifies eight surveyors (2 teams of 4) to participate in initial round (core) of QIS training  Minimum of two years of recent LTC survey experience  SMQT qualified  Possess intermediate computer skills  Prior teaching or training experience, if possible  State selects four QIS trainer candidates from initial core group of surveyors trained in QIS 34

35. Educating Stakeholders on QIS & State’s Implementation Plan  Dedicate a section of State Web site for QIS information and resources for stakeholders  Schedule, announce and participate in “Overview of QIS for Stakeholders” with CMS and NHQ  Communicate with stakeholders regarding the QIS process and the QIS implementation in the State on an ongoing basis  Stakeholder education is key to successfully implementing QIS 35

36. Preparatory Logistics and Tasks for Core Group QIS Training  QIS Classroom Logistics Checklist call with NHQ  QIS IT Logistics Checklist call with NHQ  Schedule 1-Day IT Training led by Alpine Technology Group for State’s IT staff  Secure all necessary equipment for QIS training  Determine classroom location and nursing homes for mock (simulated training)survey and surveys of record  Load and test participant tablets PCs with QIS software/files  State led computer orientation training for surveyors participating in QIS training *Please refer to the QIS Training Timeline document and QIS Classroom Logistics Checklist for a detailed list of logistics 36

37. QIS Classroom Training 37

38. Training Requirements for Registered QIS Surveyor  Prerequisites  Proficiency with tablet PC functions and computer skills  Completion of classroom training  Participation in mock training survey  Participation in surveys of record with successful compliance assessment  Documentation in CMS Learning Management System (LMS)

39. 39 Initial (Core) QIS Training Example

40. QIS Train-the-Trainer (T3) 40

41. Training Requirements for CMS-Certified QIS Trainer  Be Registered QIS Surveyor  Successfully complete additional requirements  Complete at least six QIS surveys of record  Attend Train the Trainer workshop  Provide the QIS classroom training  Monitor surveyor-students in mock survey  Conduct compliance assessment for surveyor- students during a survey of record  Remain actively involved in QIS training/surveys  Documentation in CMS Learning Management System (LMS)

42. 42 QIS Train-the-Trainer (T3) Schedule Example

43. Tips for a Smooth QIS Training  Provide a comfortable classroom learning environment and furnish required equipment  Educate State management about QIS  Supervisors participate in training  Recognize the learning curve and additional time needed to complete QIS (Plan on a minimum of 40 in-facility hours per surveyor per week)  To the degree possible, select facilities for the mock & surveys of record that do not have a history of serious care issues and consider commute time for surveyors  Avoid adding tasks such as licensure review to QIS surveys during initial QIS training activities 43