Simply put, the Quality Indicator Survey (QIS) is the most comprehensive regulatory change to the nursing home survey process since the Omnibus Budget and Reconciliation Act of 1997 (OBRA) was enacted. QIS is a major paradigm shift in the assessment of compliance, care delivery and quality of life indicators and is largely based on MDS data. Following over a decade of development, the Centers for Medicare and Medicaid (CMS) started the national rollout in 2007. Since that time, numerous states have implemented QIS with nearly 20% of U.S. nursing homes receiving QIS surveys in 2010. While Federal funding cuts temporarily delayed the banded roll-out, have no fear, QIS is still coming your way.
From a historical perspective, it’s important to note that the original intent of OBRA called for substantial change in the regulatory process to improve consistency and increase the focus on resident outcomes. Over the past several years, CMS has been moving in this direction with the introduction and subsequent refinement of a resident assessment instrument (RAI), better known as the Minimum Data Set (MDS), in addition to case-mix adjusted reimbursement, standardized resident assessment protocols and the electronic transmission and storage of resident data.
So, why the need for this landmark change from a traditional survey model to QIS? Some of the main objectives of the QIS process are to:
- Improve consistency and accuracy of quality of care and quality of life problem identification by reducing subjectivity and using a more structured survey process;
- Enable timely and effective feedback on survey processes for surveyors and managers;
- Systematically review requirements and objectively investigate all triggered regulatory areas;
- Provide tools for continuous quality improvement;
- Address issues that are most important to the industry, residents and family members;
- Enhance documentation by organizing survey findings through automation, ultimately moving to a paperless survey process; and
- Ensure consistent and fair application of regulations from state to state and surveyor to surveyor
In the nutshell, QIS is a computer assisted long-term care survey process used by selected State Survey Agencies and CMS to determine if Medicare and Medicaid certified nursing homes meet Federal guidelines for nursing home care. Based on a two-stage quality assessment approach first developed at the University of Colorado in 1993, surveyors systematically review specific nursing home requirements and objectively investigate any regulatory areas that are triggered. Although the survey process has been largely revised under the QIS model, it’s important to note that the Federal regulations and interpretive guidelines remain unchanged.
Understanding the QIS structure and survey process, particularly as it applies to how providers manage and improve MDS data, is key to ensuring good survey outcomes and preventing unintended consequences, such as a reduction in Five-Star rating, major fines and citations, negative publicity, to name a few. Since the MDS data is reviewed during the pre-site visit stage, it is used to create the resident pool from which record samples are randomly selected and to calculate the Quality of Care and Quality of Life indicators, of which there are 162, far more than those comprising the MDS.
While this article will not provide a complete overview of the survey process, all of which can be found on the Centers for Medicare and Medicaid website, below is a comparison chart which provides some level of detail:
Now, consider this notion. Since the QIS process is a significant step toward a more resident-centered approach and consistent survey process, why not embrace evidence-based practice, new quality assessment and assurance norms and culture change by linking the regulatory process with internal quality improvement activities? There’s no better time to make QIS process tools and resources part of an overall quality assurance performance improvement plan (QAPI). Not unlike QIS, QAPI is a data-driven, proactive approach to improving the quality of life, care and services in nursing homes. QIS tools and protocols range from resident, staff and family interviews, facility-level tasks, resident observations, etc.
When developing a QAPI plan that will merge the resident-centered focus and systematic approach to assessing quality of care and life in the QIS process, an essential beginning is to create a culture of responsibility and accountability that is fully vetted and supported by top management and includes input and support by team members, residents and family members at all levels of the organization. While the QAPI process is never ending and must be systemic, there must be a strategy in place to collect, use and post data, identify gaps and opportunities for improvement, plan and conduct projects and measure against targets. By using best practice tools and techniques, such as checklists, audits, structured observations and direct interviews, teams should monitor a number of clinical, financial and operational triggered care areas, always keeping a sharp focus on MDS and other publicly reported data. The importance of accuracy goes well beyond preparing for annual surveys, since it could also impact Medicare/Medicaid reimbursement, quality care and care planning, securing revenue for quality care provided, etc.
While understanding and integrating the new QIS survey is but part of the journey, there are many elements to managing the survey process that must be considered and properly managed. The following “top ten” suggestions are a compilation of best practices that will get providers on the right track:
- Empower and educate staff, residents and family on the QIS process;
- Monitor data carefully – everyone is looking at it (Nursing Home Compare);
- Be visible and follow-up on any concerns or issues promptly;
- Implement a mock survey/peer review program and seek out external support;
- Utilize tools that are not part of QIS to build a comprehensive compliance program;
- Integrate into an MDS/chart auditing process as part of an overall compliance plan;
- Enhance documentation systems;
- Don’t be a follower: implement evidence-based practices and be a champion;
- Develop a QAPI process that touches every corner of the facility and involves staff, residents and family at all levels of the organization; AND
- Share information with staff – open lines of communication and transparency are key to having a happy and engaged team.