Title: QIS The Survey Conundrum: Know the Answers to the Questions before the Surveyors
1QIS - The Survey Conundrum Know the Answers to
the Questions before the Surveyors
- PRESENTERS
- Kelley Rice-Schild, NHA, Amina Dubuisson, DON,
Floridean Nursing Rehab, Miami, FL - Connie ODonnell, NHA, All Saints Catholic
Nursing Home, Jacksonville, FL - Alex Terentev, M.D., NHA, Rosewood Manor,
Pensacola, FL - LuMarie Polivka West, MSP, Senior Vice President,
Chief of Clinical Services, Florida Health Care
Association, Tallahassee, FL - AHCA/NCAL 59th Annual Convention 2008
2Session Objectives
- Learn about the QIS process and the use of
interviews in the process. - Understand how research supports the interview
process in QIS. - Learn how a facility that has had the QIS process
has used interviews to improve the quality of
care and also improve their survey outcome.
3Background
- A revised survey process
- Contract awarded in 2005 with University of
Colorado to conduct demonstration - Independent evaluation of demonstration (Abt
Associates) - Florida is participating with the statewide roll
out of the QIS
42 Stages of the Quality Indicator Survey
- Stage I Preliminarily investigate all
regulatory areas and determine care areas for
in-depth Stage II review - Stage II Determine if deficient practice, and
document deficiencies including F tags, scope and
severity
5Stage I Entrance
- Entrance Conference held during which necessary
information is requested from facility (see
Entrance Conference Facility Worksheet), i.e.
alphabetical roster (this has been identified as
a problem by AHCA) - Abbreviated Tour (concurrent to entrance
conference) to provide orientation goals are
different than traditional survey tour (no
selection of resident sampling)
6Within One Hour
- Key personnel and locations
- Name of resident council president
- Meal time schedule and dining room location
- All admission sample closed records
- List provided to facility after entrance
conference
7Within Four Hours
- Ventilator/Dialysis/Hospice Worksheet
- Dialysis contract and related policies overview
of how care is coordinated - For facility dialysis List of residents, room,
and ESRD caregiver and who provides the service
(internal or external provisions) - Day and times for dialysis treatment
- Flu/Pneumococcal PP
8Within 4 Hours cont.
- Rooms with less than required square footage that
have a variance - Lists of rooms 4 residents (variance)
- Rooms below grade no window to outside or access
to a corridor - QAA committee info Contact persons, members,
frequency of meetings - PASSAR information
- Any experimental research in the facility
- Complaint/Abuse/Grievance info contact person
and PP
9Within 24 Hours
- Medicare residents that have requested demand
billing since last survey (9-15 mo) - Medicare/Medicaid application (671)
- Resident Census and Condition (672)
- Copy of the OSCAR 3
- Query Is full time DON coverage provided?
10Stage I Sampling
- MDS sample drawn offsite and includes all
residents with an MDS assessment within the past
6 months of the survey - Census sample - random sample of current
residents (n40) - Admission sample - random sample of new
admissions (n30)
11Stage I Resident Level Investigation
- Resident Interviews
- Resident Observations
- Staff Interviews
- Medical Record Reviews
- Family Interviews
12Stage I Facility Level Investigation
- Resident Council Interviews
- Observations of Dining and Kitchen
- Infection Control Practices
- Demand Bill Procedures
- Quality Assessment and Assurance Program
13Stage I Synthesis
- Onsite data are combined with MDS data to
- create resident-centered outcome and
- process indicators, called Quality of Care
- Indicators (QCIs)
- QCIs and Facility-level Tasks
- MDS (includes the 24 QI)
- Census
- Admission
- Facility
14Admission Sample Review
- Prognosis
- DX
- LOS
- Discharge info (if applicable)
- Within 60 days of admit Any PT, OT, ST?
- Pressure ulcer, weight loss, Terminal prognosis
15Census Sample
- Comatose
- Bed mobility
- Transfer
- ICD 9 codes that focus on nutrition
- Stability
- Pressure Ulcers
- Psycho tropics
- Weight Loss
16Family Interview
- Want to understand why it is like to live in
this nursing home - Determine through screening the level of
resident knowledge - Prior Hx
- Preferences Are they honored?
- Choices
- Activities
- Dignity Interactions
17Family Interviews
- Staffing - Is it sufficient?
- ADL
- Oral Health
- Abuse
- Personal property
- Environment
- Rights
- Costs/Funds
- Admission
- Notice of changes
- Care plan participation
18Resident Interview
Openers How long have you been here, are you
from around here, what is the food
like? Cognitive determination If cognitively
appropriate the questions entail quality of life
and care
19Resident Interview Cont.
- Abuse Do you ever feel afraid
- Personal property
- Skin condition
- Potential restraints device in place that may
potentially restrict movement or access to ones
body - Pain observations also done
- Food
20Resident Interviews
- Staffing
- Oral Health
- Positioning
- Privacy
- Exercise of rights
- Funds
- Room
21Staff Interviews
- Catheter use reason diagnosis
- Neurogenic bladder must be verified in medical
record - Nutrition supplements and reasons for
- Skin Care Protocols
22Facility Survey Tasks
- Demand Billing
- Dining
- Frequency of meals
- Assistance
- Meal service and proper handling
- Dignity and independence
- Adequate time
- Positioning (maximized eating ability)
23Facility Survey Tasks cont.
- Atmosphere
- Substitutes
- Furnishing/space
- Food quality and sufficient liquids adequate
assist as needed
24Infection Control
- Observations for hand washing (Competency tool)
- Glove use
- Staff with lesions?
- Soiled laundry process
- Isolation
- Functioning infection control program
- Staff adherence to PP
25Kitchen/Food Service
- Tour
- Storage
- Food Infection control guidelines
- Storage temperatures and process
- Food prep and service includes snacks, leftover
storage, etc. - Sanitization
- Equipment
26Stage II Sampling
- Computer identifies sample such that all
triggered care areas are included with as few
residents as possible - The more care areas triggered, the larger the
sample - All sentinel events and complaints
27Stage II Resident Level Investigation
- Each surveyor evaluates care process in relation
to Stage I findings - Both resident-level and facility-wide
investigations - Use of Critical Elements Pathways to structure
investigative process - Rate severity for each resident where deficient
practice is found
28Stage II Facility Level Investigations
- If triggered in Stage I
- Abuse Prohibition
- Environment
- Nursing service
- Sufficient staff
- Resident funds
- Admission, transfer, and discharge
29Stage II Synthesis
- Combine Stage II findings across residents into
single computer by F tag - Integrate survey team findings into single
statement - Use documentation recorded in Stage I and Stage
II - Identify deficiencies and determine severity and
scope - Upload directly to 2567
30Surveyor Initiative
- At any time in the process,
- surveyors can initiate the addition
- of
- Residents
- Care areas
- F tags
31Medication Observation
- Medication administration observation is assigned
to specific surveyors during offsite preparation - Medication administration observation is
conducted throughout the survey - Documentation is completed during Stage II
32Medication
- 10 resident sample
- Preparation
- Administration correct dose, order, and given
per appropriate technique and order - Storage
- Staff need a working knowledge of medications
- Beyond the med cart survey success
33CMS QIS Process Strengths
- Larger Sample Sizes
- To identify patterns of poor care
- Different samples (e.g., admission and census)
emphasize different types of residents. - Comprehensive
- Past studies demonstrated that some surveyors
targeted only selected deficiencies while missing
the big picture - Staged approach requires surveyors to examine all
regulations
34Structured Approach
- Systematic observations and questions are
comparable across sites and replicable - Providers could use the tool to reliably assess
and improve quality on an ongoing basis
35Learn the QIS process
- Read and Learn
- the Manual !
36We Earned a Deficiency Free QIS Survey!
37All Saints History
- Independent
- Non-Profit
- 53 years of caring
- 6.2 years average employment (range 1 week 29
years) - 120 Residents
- 87 long term care
- 19 Bed Secured Alzheimer Unit
38Survey History
39Opportunity to host a Mock Survey
40Pre-Mock Preparations
- Read QIS Manual
- Reviewed systems in place
- Questioned residents
- Explained QIS process to residents, staff,
families - Prepared Survey Book
41Pre-Mock Expectations
- Learn about QIS process
- Survey-prep
- Positive outcome
42Mock Reality
- Little communication with management
- If didnt find info, often assumed not there
- Staff not ready for questions asked
- Residents didnt always understand questions
- EVERYONE uncomfortable with process!
- 18 mock federal citations state crossovers
43(No Transcript)
44Staff Education
- Supervisors must understand Critical Pathways
how they impact care - All staff must understand intent of QIS
- Explain QIS process and what their role is
- Prepare for use of computers
- Prepare for questions that may be asked
- Establish a communication plan for Survey
45Resident Interviews
- Use questions from QIS Manual
- Familiarize residents with what the questions are
asking - Lets you know what they really think
- Good basis for CQI projects
- Gives residents a voice in their care
- Act on the answers! Care plan issues that arise
from questions
46Care Plan Adjustments
- Software changes
- Highlighted key approaches that meet regulation
intent - Verbiage modification
- Bring Nursing Aide Care Plan to Care Plans
- Verify MDS info is actually located in chart
47Quality Indicator Review
- Great QIS Tool!
- Review residents who trigger in multiple areas
for QIS concerns. - Review flagged areas for QIS concerns.
- Incorporate QIS-related concerns into your CQI
process. Be able to address all areas of concern
before QIS Survey.
48Find the Key
- The key to the QIS puzzle is different for each
building. - It is the one thing that brings everything
together in your building. - You dont need to reinvent your systems.
- Just find the key.
- Its already there.
- Look for it!
49All Saints Key
- The Nursing Aide Care Plan
50Nursing Aide Care Plan
- Located 2 places CNA Book inside resident
closet door - Verify both Care Plans match
- Verify Nursing Aide Care Plan matches resident
care plan - Quiz CNAs
51(No Transcript)
52(No Transcript)
53Survey Day Tips
- Have info ready when they come in!
- Admission List
- Resident Census
- HCFA 672
- Survey Book (use surveyor checklist)
- Let your staff know you trust them
- Use your communication systems
54Same Old, Same Old
- Facility appearance odor important
- Happy, smiling residents staff
- Interactions activities observed
- Dining observed (intensely!)
- Personal items stored labeled
- Weights Skin Sheets easy to find
55(No Transcript)
56QIS
- Improvement Process
- Rosewood Manor
57Quality of Life Activities
58Psychosocial Aspect
- Sensitivity Training for employees
- Enhancing activities
- - 15 minutes per C.N.A.
- - Train CNA in activities for low cognition
residents - - Quality of Life activities (tea party,
band, aromatherapy, etc.)
59Department Specific Tasks
- Stage 1 Forms Survey Tasks (from manual) copied
and distributed to departments Business Office,
Nursing, Dietary, etc - Critical element pathways reviewed by Department
Heads
60Our Focus
- To improve residents quality of care and quality
of life by enhancing - Associate and residents interactions
- Resident and residents interactions
- Associate and associate interactions
61 Overwhelmed
62Central Command
- Administrators office for high visibility
- Wall charts progress of specific tasks,
resident/family interview concerns, dining
observations, etc - Standing flip chart - rounds results / follow-up
63Rounds
- Weekday Department Managers
- Every morning at 630
- 3 department managers / one a nurse
- Specific things to observe - guidelines
- Daily report at stand up (flip chart)
- Follow up on issues and concerns at next stand up
(most important) - Evening, Night, Weekend - Supervisors
64Recognition
- Thank you Thursday (wall tracking chart)
- Department Heads offered opportunity each
Thursday in Stand Up to write thank you notes - Goal to improve the associate to associate and
manager to associate interaction / relationships - QIS Survey looking for teamwork and comfortable
working relationships among staff as well as
between residents and associates.
65Dining Room SupervisionNurses
- Schedule of nursing supervision posted
- Guidelines updated and posted at Nurses station
Dining Room - - Focus on interactions between associates and
residents - - Include all areas that meals were served
(including resident room)
66Dining Room CQI
- Use Dining Room Observation Form
- CNA, Nurse, or Supervisor
- Observer to meal, documenting observations
- Involved staff in PI process
- Better than in-services for staff education
67Nurses Weekly Audit
- Nurse Managers Unit Managers
- Assigned to an area of 16 20 residents
- Same assignment for survey
- Specific audit tool developed
- (from ideas/forms obtained from other
facilities) - Completed audits to DON
- Issues identified and addressed
68Nurses Audit Tool
- Revised from original to be more manageable with
weekly tasks - Week 1 Med rooms, diets, chart audit
- Week 2 Restraints/alarms, ADL log, interviews
- Week 3 Skin, treatments, labs
- Week 4 Med Pass, MARs, medications
69Standards of Care Meetings
- Weekly with Care Plan Team
- Focus each week on different area Skin,
Restraints, Psychotropic, Weight, Catheters - Charts brought to meeting
- Specific audit tools for each topic
- Documentation in department notes, appropriate
forms completed and care plan updated during
meeting
70What does this resident want???
71Activities Questionnaire
- Goals Focus on a psychosocial aspect
- Staff learn more specifics about resident
- Completed by Staff nurses and CNAs
- Interviewed resident / or family
- Each nurse/C.N.A. completed 1-2 interviews
- Became a great resource for Care Plans
72(No Transcript)
73Resident Council President Interview
- Completed by Administrator
- Surveyors only interview Resident Council
President, no longer conduct group interview
74Residents Interview
- Social Service identified interviewable residents
(using QIS form) - Interviewed all appropriate residents using
Resident Interview Resident Observation form. - Interviewed selected family members using Family
Interview form - Reviewed in Stand Up and follow up on any
concerns.
75- Reasons for a
- Deficiency Free Survey
76We Knew Our Residents
- Told us the information from every CNA they
interviewed matched what was in chart. (CNA
interviewing residents helped a lot) - Nurses able to talk about residents during nurse
interview with minimal time searching through
chart and MAR (also comfortable with where
information located in chart)
77Resident Information Matched
- Part of computer analysis is comparing similar
data from resident interview, family interview,
chart audit (notes, MDS, care plan). The
computer highlights areas that do not match. - We had no highlighted areas. All our data
matched!
78Resident and Associate Morale
- Residents and families for the most part happy
- Residents wanted facility to do well
- Staff would go the extra mile for residents
sewing, fixing meals in therapy, making hats for
tea party - Staff gave positive statements to surveyors about
management - Team work CNAs, nurses managers all working
together
79Rounding
- All shifts involved in rounds and knew we were
consistently observing what we were expecting.
Staff complimented immediately as improvements
seen. - ALL Department Heads involved and on the same
page. - Non-nursing Department heads learned what to
observe. Sometimes saw things nursing too close
to see. - Staff and residents saw a Department Head daily
opportunity to address concerns immediately.
80More Accurate Charts
- Standards of Care Meeting with charts audit for
Dr.s order, nurses notes, restorative note,
dietary note, justification (catheter), consent
(restraints, psychotropics), MDS, Care Plan
accuracy - Falls/Incidents Reviewed daily with chart at
Nurse Management Meeting. Checked for
documentation, appropriate interventions, orders,
and care plan updated, - Care Plans Something very resident specific so
you could recognize resident without name on care
plan. (this is where Activity Questionnaire also
helped)
81Med Pass
- Aimed for every nurse manager to observe 1 nurse
weekly, occurred every 2-3 weeks - Pharmacy a big problem had to have nurses
checking all meds and documenting missing on 24hr
report for ADON/DON follow-up
82Closed Charts Organized
- Easy for surveyors to find what they are looking
for without looking through entire chart. - Note Be sure skin sheets, weekly wound forms
and weights are easy to find
83Conclusion
- We have a lot of areas for improvement at
Rosewood and the surveyors observed many of them,
BUT the residents were happy, involved and the
associates had good relationships with the
residents and each other - This was reflected in the data entered into the
computer first 2 days (Stage 1), resulting in
very few areas they needed (or were allowed) to
dig deeper into during Stage 2 - They did not ask for infection control, skin
books, or any policies or procedures. None of
these areas triggered in Stage 1