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Long-Term Care Survey Alert

Quality Improvement:

Use The New QI/QM Reports To Stay A Step Ahead Of The Survey Curve

Published on Sat Aug 27, 2005 Print Friendly and PDF PDF

Don't let the QIs/QMs boomerang on you.

If there's a "cheat sheet" in the survey world, the quality indicators/measures are it, so make sure you use them to your advantage.

Otherwise you won't know which residents and potential problem areas are on surveyors' radar screens until the F tags start flying.

Start by making sure you know how to access all of the reports surveyors will use to prepare their offsite resident sample selection. (Review a PowerPoint presentation that walks you through how to access the reports on the CASPER system at www.qtso.com/download/mds/MdsQiQmRptAccessFacility.pdf.)

If a facility has been using CASPER, it will have fewer problems accessing the reports than one that isn't used to navigating the system, which wasn't necessary previously to obtain the QI reports, says Judy Wilhide, RN, BA, RAC-C, RAI manager for Virginia. "The user ID and password for CASPER are the same as the one the facility uses to sign onto the state MDS system," she says.

"Once you're on the CASPER system, click on reports and you'll see eight different things you can click on," says Wilhide. "One of them says MDS QI/QM package, which includes all of the reports that surveyors will have to prepare their offsite resident sample selection."

The package doesn't include one report, which is the Quality Measure/Indicator Monthly Trend Report, a graph or visual representation comparing the facility to state and national averages on each QI. "The facility can select the timeframe for comparison, e.g., whatever months the facility chooses," says Wilhide. The report is in color, but you'll need a color printer to take advantage of the color, she adds.

Time-saving tip: The system will allow you to save the reports in several formats, Wilhide says. Facilities can export the QI/QM reports in PDF form from CASPER to their own computer system, for example, which allows staff to share the reports electronically and save time and paper, she advises.

Know How, When to Target QIs/QMs

Facilities should first target any QI/QM where they score at the 70th percentile or higher so they can get a head start on an upward trend, advises Wilhide. Look at each resident who flagged the QI/QM - and any resident who triggered a QI that's a sentinel event (e.g., fecal impaction, low-risk pressure ulcer or dehydration). As part of the QA analysis, ask these key questions:

  • Is the resident's MDS that triggered the QI/QM coded correctly? Look at the actual MDS items that trigger a QI/QM and the risk adjusters or covariates to see if you've captured and coded them correctly. (Review the MDS coding for the QIs at www.qtso.com/download/mds/MDS_QIQM_Tech_Specs.)

    For example, is staff coding urinary tract infection that doesn't meet the RAI manual requirements? (For more information, see chapter 3 of the manual, p. 3-136, at www.cms.hhs.gov/quality/mds20/raich3.pdf.)

    "If the MDS isn't coded correctly, make the necessary corrections and transmit them to the database quickly," advises Wilhide.

    Editor's note: For an in depth look at common assessment and coding problems that can wreak havoc on your quality indicators/measures, see the October 2005 MDS Alert. For information about how to subscribe, go to     www.elihealthcare.com/spec_mds.htm.
  • If the MDS is correct, does the triggered QI/QM represent a care shortfall or an unavoidable outcome? To answer this question requires an in depth, honest evaluation, advises Wilhide. Staff should ask themselves if the team missed something in assessing the resident's risks - or if the care plan fails to address identified risks. If an outcome appears to be unavoidable, "does the clinical record consistently paint that picture?" asks Wilhide.

  • How can the facility take corrective action to improve an area of care reflected by a QI/QM? In making this determination, review your policies and procedures and care, advises Cathy Sorgee, RN, a consultant with The Broussard Group in Lake Charles, LA. "Make sure to look for system failures - and not just employee failures," she adds. "Identify which part of the system needs to be changed - and then develop and implement a plan of action, including staff education." Then review the care and QIs to determine if the plan worked. "If not, create a new plan of action and continue the process until you find one that solves the problem," she says.


    For example, if your UTI QI is high, look for systemic assessment and care issues causing the problem, suggests Reta Underwood, a survey consultant in Buckner, KY. Examples include poor hydration, lack of a regular toileting program, failure to check and change residents frequently enough - or improper pericare.

    Real-world example: One nursing facility reduced its rate of falls by doing a fall care plan for any resident with even one fall-risk factor on their fall risk assessment tool, according to nurse Karen Russell in a presentation at the most recent annual American Association of Homes & Services for the Aging conference. "That approach contrasts to the more traditional approach of assigning risk scores and then care planning only moderate to high-risk residents."

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