Nursing Home Quality Indicator Reports--Maximizing Your Information

Nancy Day, RN, CRRN, CLNC; Tracy Kania, RN, BSN, CRRN

The Nursing Home Quality Indicators mandated by HCFA provide a valuable source of information for facilities to consider in enhancing their efforts to provide and assure quality care and services. While these quality indicators are not all inclusive, they do provide a method for facilities to review the same information that is being provided to their state regulatory agencies via electronic transmission of completed MDS assessments.

Most importantly, facilities need to remember that information included on the reports is only from transmitted MDS assessments that have been accepted by the state. There are specific types of assessments included on the specific reports. The Quality Indicator reports can be retrieved by facilities from their state database at the same location used to transmit their MDS assessments. This information is not available to the public but is available to the facility at any time the facility wants to retrieve the reports.

To begin to maximize the Quality Indicator information you must understand the Quality Indicator reports. The three reports generated from transmitted assessments include the Facility Characteristics Report, the Quality Indicator Profile Report, and the Resident Level Summary Report. States may also offer other types of reports, such as a Resident Listing, Data Submission Summary and Assessment Summary.

In order to maximize the information, facility staff must first understand what information the reports provide. The Facility Characteristics Report contains the number and percentage of residents with certain demographic characteristics as defined in the report. The characteristics on the report include Gender, Age, Payment Source, Diagnostic Characteristics, Type of Assessments, Stability of conditions, and Discharge Potential. For each characteristic, the report lists the number of residents having the characteristic, the percentage that is present in the facility and also the percentage of the comparison group; the comparison group is the other state facilities. You need to keep in mind that these percentages and numbers may not be all inclusive as there may be assessments that have not yet been transmitted and/or accepted by the state.

To maximize the information on the Facility Characteristics Report, facilities need to consider how they might view and use the information provided. Depending on the type of facility, the demographic information may alert the facility to different things. For example if the number of male residents was higher than average, the facility may want to be sure the activities are reviewed to be sure they are appropriate for this gender group. Also, items such as type of assessments might indicate a need to research high numbers of corrections or significant changes. One might look at the stability of conditions. If the number of end-stage disease is significant, the facility may want to look at the number of residents receiving Hospice; and if that number is low in comparison to the end-stage, the facility may investigate to be sure residents are aware of their rights to utilize Hospice. Any of the information on this report may prompt the facility to conduct a review of specific resident groups.

Probably one of the most "talked about" reports is the Facility Quality Indicator Profile Report. This report is utilized to identify possible areas for further emphasis in the facility quality assurance program or for use by surveyors to identify potential areas for investigation during the survey process. It is important to remember that this report does not include transmitted "admission" assessments. This report, see Figure 1, includes 24 Quality Indicators grouped within 11 domains.

The Facility Quality Indicator Profile Report gives you the following information: the actual number of residents who flagged the QI, the number of residents who could have flagged the QI, the percentage of the residents who could have the QI that actually did have it, the comparison group percentage when compared with the state wide facilities, and the percentile rank of the facility when compared to other facilities in the state for each QI.

There are flags on the report that indicate any QI that falls in the 90th percentile or higher and any sentinel event QIs. The Sentinel Event QIs include # 11--Prevalence of fecal impaction, # 15--Prevalence of dehydration and # 14--prevalence of Low risk pressure ulcer. Facilities need to remember that just because a QI has flagged does not mean that there is an automatic assumption that a problem exists. It does suggest that there may be a concern and the condition should be investigated to assure a problem does not exist.

New Day Professional Services Consultants utilize the Quality Indicator Profile Report to identify areas that possibly need to be investigated. Even though QIs with a percentile of 75 percent or greater are not flagged on the report from the state, many survey agencies use the 75 percent as a threshold for investigation. For this reason, New Day Professionals review any QI that is 75 percentor higher as well as all sentinel events. (Any number of Sentinel events should be investigated, even if there is only one.) An important thing to remember is that the QIs should not be the only source the facility uses for their quality assurance activities, but rather an important component of their quality assurance activities. To maximize the QI information and facilitate further investigation of selected QIs, facilities should identify what their policies and procedures are for care planning for each of the QI areas. For example, what are the policies/procedures for caring for incontinence residents? Is there a required assessment, retaining evaluation, toileting program etc. that should be instituted for all incontinent residents? If so, is this being implemented consistently on all incontinent residents? If it is being done and being done consistently and accurately, then there may not be a problem existent with a QI that flagged in this area even if the percentile is high.

Another important thing to remember is that all the information utilized to compile the Quality Indicator reports comes from the transmitted MDS assessments that are applicable to each report type. When review of the flagged indicators reveals that the assessment has been completed with an error that impacts the QI profile, especially the sentinel event ones, the facility should consider submitting a corrected assessment to assure the state database contains the correct information. Facilities should consider and review the clinical links among the Quality Indicator Domains and Quality Indicators. For example, Accidents can be impacted by new fractures, falls, use of 9+ medications, weight loss, dehydration, decline in late loss ADLs, and psychotropic drug use and daily physical restraints. For a listing of these clinical links and all the information regarding the Nursing Home Quality Indicators, facilities can obtain a Facility Guide for The Nursing Home Quality Indicators from the Center for Health Systems Research and Analysis, University
of Wisconsin– Madison. You may also access their Website: http://www.chsra.wisc.edu/ Default.htm

The third QI report that is available through the state database is the Resident Level Quality Indicator Summary. This report lists all the active residents as well as the Discharged Residents and places a check mark in the column of any of the 24 quality indicators that was flagged by the submitted assessment on a particular resident. It also lists the total number of indicators flagged on each resident. It also lists the assessment reference date and the type of the assessment from which the QI was obtained. This report includes the following type of transmitted assessments: Admission, Annual, Significant Change in Status, Significant Correction of prior assessment, Quarterly review, Significant correction of prior quarterly assessment. This report allows the facility to review all the quality indicator areas that have been identified for a particular resident. To maximize the use of this information, New Day Consultants utilize this report to do the following for the facilities in which they consult:

1. For each identified indicator--Are there identified policies and procedures for care of this condition; are they current and according to best care practices?

2. For each identified indicator--Was the MDS item that caused this indicator to flag accurately documented on the MDS?

3. For each identified indicator--Was the facility policy and/or procedure appropriately implemented for the resident?

4. For each identified indicator--If appropriate, was this condition care planned and appropriately documented on the care plan?

5. For each identified indicator--Was there documentation in the medical record that validated the condition as it was represented on the MDS?

6. Problems identified with in any of the above areas are assessed and recommendations made for improvement, QA audits developed, and inservices planned where needed.

Facilities should view the Quality Indicators and the Quality Indicator Reports as tools to assist them in assuring they are doing everything possible to promote quality of care and quality of life for the residents. The tools can certainly help facilities keep on top of conditions that may be investigated during surveys and allow them to be proactive rather than reactive. The best way to maximize the information is to look at it and require a timely review of the reports by the QA teams and appropriate staff members. Facilities who want to really be proactive utilize software programs such as that provided by Achieve Healthcare Information Systems that will allow them to review the reports prior to locking or submitting the MDS so that problems can be identified prior to submission and possible errors corrected. Also some software systems will allow facilities to even review what will flag on an individual resident prior to closing the MDS so that any questionable items can be reviewed.

Conclusion

In conclusion, The Nursing Home Quality Indicators mandated by HCFA provide a valuable source of information for facilities to consider in enhancing their efforts to provide and assure quality care and services. However, it is up to the facilities to utilize this information – to be innovative and appreciate the positive outcomes that can be achieved proactively by making the Quality Indicators a viable part of the facility Quality Improvement or Quality Assurance Activities.

Contact: Website www.chsra.wisc.edu

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The Facility Quality Indicator Profile Report includes 24 Quality Indicators grouped within 11 domains. The following 11domains and 24 quality indicators are included on this report:

1. Accidents

2. Behavior/Emotional Patterns

* 3. Prevalence of behavior symptoms affecting others

* High Risk

* Low Risk

3. Clinical Management

* 6. Use of 9 or more different medications

4. Cognitive Patterns

* 7. Incidence of cognitive impairment

5. Elimination/incontinence

* 8. Prevalence of bladder or bowel incontinence

* High risk

* Low risk

6. Infection Control

* 12. Prevalence of urinary tract infections

7. Nutrition/Eating

8. Physical Functioning

9. Psychotropic Drug Use

* 19. Prevalence of antipsychotic use, in the absence of psychotic or related conditions

* High risk

* Low risk

* 20. Prevalence of anxiety/hypnotic use

* 21. Prevalence of hypnotic use more than two times in the last week

10. Quality of Life

* 22. Prevalence of daily physical restraints

* 23. Prevalence of little or no activity

11. Skin Care

* 24. Prevalence of stage 1-4 pressure ulcers

* High Risk

* Low Risk – SENTINEL EVENT!