What is CMS planning for the standard survey process, with both the traditional and QIS processes currently in use?
What I know about revisions to the standard survey comes from the October 2015 Government Accounting Office (GAO) report, “Nursing Home Quality: CMS Should Continue to Improve Data and Oversight” (GAO-16-33).
GAO highlighted the following issues:
■ Trends of increased complaints, decreased deficiencies, increased staffing hours, and improved Quality Measures (QMs), although “data issues complicate the ability to assess trends in nursing home quality over time.”
■ A decline in average number of deficiencies between 2005 and 2014, which “may indicate an improvement in quality, may also be attributed to inconsistencies in measurement.”
A research study using early data about the Quality Indicator Survey (QIS) that one of my colleagues and I published was consistent with these findings.
The study showed that when the process was implemented, QIS states became more similar on the number of deficiencies over the first couple years, but with an average of about two more deficiencies, particularly in areas related to quality of life (Lin, M., and Kramer, A. “The Quality Indicator Survey: Background, Implementation, and Widespread Change;” Journal of Aging & Social Policy, 25:10–29, 2013).
However, over time, survey results improved in the QIS states consistent with improving quality based on the more explicit QIS compliance measurements.
So over this nine-year period of the GAO report, we would expect to see declining deficiencies in QIS states, but improvements in other measures of quality such as QMs and staffing since these constructs are measured in the QIS process.
GAO acknowledged the challenge of consistent measurement with two survey processes: “One reason these measurement inconsistencies occur is the use of both traditional paper-based surveys and QIS electronic surveys…” where “As of late 2014, 23 states used QIS surveys, 25 states used traditional, and three states used both.”
To address the different survey methodologies, CMS officials told the Office of Inspector General (OIG): “…they plan to develop a hybrid model of the QIS and traditional surveys, with the long-term goal of moving all states to this hybrid model.”
CMS also responded to GAO that it is “developing a plan for improving efficiency and effectiveness of the survey process, using data collected and input from stakeholders.” As stakeholders I urge you to provide constructive feedback to CMS on the QIS, traditional, and any new hybrid model.
From my perspective, my hope is that a new hybrid survey process will maintain the objective approach of the QIS methodology, with random sample selection and standardized investigation protocols. I know from my experience of working with thousands of providers that incorporating the QIS methodology as part of their Quality Assurance and Performance Improvement program has helped them to improve compliance, and to provide improved resident-centered care.
CMS officials, with whom I worked on QIS, believed that a more replicable process should result in more explicit measures and standards that providers could use in their QAPI programs, and ultimately improve quality and compliance.