The True Legacy of QIS
While anecdotes and rumors abound regarding experience with the QIS process, little attention has been given to the first published study of QIS. It often takes several years to investigate the effects of changes as far-reaching as QIS. This is especially true during a gradual rollout requiring new resources, training, and, most significantly, a major cultural shift in well-established norms.
The study, published in the Journal of Aging and Social Policy in 2013, examined the first 3,400 QIS surveys conducted between 2004 and 2010 (www.ncbi.nlm.nih.gov/pubmed/23256556). Surveys conducted in 2004 through 2007 were part of the QIS pilot, while the 2009 and 2010 surveys were conducted in five pilot states plus the first 14 states included in the national QIS rollout (nearly 20 percent of surveys in 2010 were QIS).
Entitled, “The Quality Indicator Survey: Background, Implementation, and Widespread Change,” the study concludes that “CMS’ implementation of QIS is a significant step toward a more resident-centered, comprehensive, and consistent survey process” (page 11).
While there is not space in this column to describe the background and implementation of QIS, suffice it to say that initial testing of the QIS method began in the early 1990s. Thus, QIS was based on over a decade of research and development and was ultimately implemented under policy pressures from the Senate and Government Accountability Office, with strong support by forward-thinking leadership in the provider and advocate communities.
‘The authors argue that the QIS emphasis on the resident’s and family’s voice helps stimulate a cultural shift.’
The paper highlights QIS impacts based on careful analysis of survey data conducted not by calendar year, but by year of QIS implementation in each state. The difficulty experienced by state surveyors in adopting the more highly structured and objective QIS process was apparent from the evolving changes in results from the first year that QIS was implemented in each state to the latter years of implementation.
During the first year, the average number of deficiencies, the proportion of facilities with quality-of-care deficiencies in areas such as Adequate Nursing Staff to Meet Resident Needs and Dental Care and the proportion of facilities with deficiencies in quality-of-life areas such as Dignity and Choices (which are explicit in QIS) were only modestly different from traditional surveys. However, in each subsequent year of implementation, as surveyors became increasingly competent in the QIS process and assessing quality of life, citations increased in all of these areas, and the difference widened between traditional and QIS surveys.
As this was occurring, the average number of deficiencies across states was found to converge, such that states with low numbers of deficiencies increased and states with high numbers of deficiencies decreased over time. Importantly, the original goals of increased comprehensiveness and survey consistency across states were achieved.
More significant for nursing home residents, however, the authors argue that the QIS emphasis on the resident’s and family’s voice helped stimulate a cultural shift in nursing centers, as both surveyors and staff adoptedQIS methods and norms. This more resident centered approach and changed expectations that “are an important component of achieving culture change in U.S. nursing homes,” is the true legacy of QIS.