QIS

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

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

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 3

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) 4

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

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

7. Comparison of QIS and Traditional Survey Process

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

9. 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 Offsite Preparation

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

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

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

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

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. Three Steps in Each Stage • Sampling (computer-generated) • Investigation • Synthesis

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. Stage 1 Triggers for Stage 2 Investigations

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. 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. 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/VideoInformation.aspx?cid=1082QIS Resource Manual: http://www.uchsc.edu/hcpr/qis_manual.phpQIS Electronic Forms and Worksheets: http://www.uchsc.edu/hcpr/qis_forms.php QIS Brochure: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter08-21.pdf Additional Information 21

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

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

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

27. DAR-SA Review • 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

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)

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=1082 • QIS Brochure: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter08-21.pdf

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

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

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

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

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

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

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

37. QIS Classroom Training

38. Training Requirementsfor 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. Initial (Core) QIS TrainingExample

40. QIS Train-the-Trainer (T3)

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. 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