Long-Term Care Survey Alert

Another round of "quality outing" is on the horizon, and it promises to give surveyors and consumers even more information about how your facility is performing.

In October, the Centers for Medicare & Medicaid Services plans to launch its new national quality initiative, which will include publicized information about how nursing facilities compare to each other on a new set of quality measures. Last month CMS kicked off its pilot initiative in six states as a prelude to the national rollout (see Long-Term Care Survey Alert, Vol. 4, No. 4, p. 42). So its time, experts say, for facilities to get up to speed on what the initiative will mean for their survey and marketing efforts (see article 5 for tips on how to explain the project to staff and consumers).

As a first step, facilities should take a good look at that pilot project now underway in Colorado, Florida, Ohio, Maryland, Rhode Island and Washington, suggests Ruta Kadonoff, a health policy analyst for the American Association of Homes and Services for the Aging. A wealth of information on the initiative is available on the CMS Web site at www.cms.hhs.gov/providers/nursinghomes/nhi.

CMS is also posting on its Nursing Home Compare Web site (www.medicare.gov) how facilities in these pilot states compare to each other on nine quality measures. Six of the outcome measures apply to chronic care residents and three are reserved for post-acute patients (see list on, article 3). Each facilitys percentage scores are compared to statewide and pilot state facility averages in a bar graph format.

While the national initiative will use different quality measures, "there is a fair amount of consistency between the quality measure domains used in the pilot and those proposed for the nationwide initiative," reports Kadonoff.

Facilities can also review the actual draft list of 13 core quality measures for the national initiative on the Web site of the National Quality Forum, the public-private partnership that developed the measures (www.qualityforum.org).

A CMS specialist tells Eli that the draft set of quality measures must go through the consensus process, which is also outlined on the NQF Web site. "The national initiative may include those proposed measures or more or less than that or even some different ones."

Facilities can use the quality measures to proactively target potential clinical issues before surveyors do. "Facilities in the pilot states will have two sets of quality measures, that is, the ones that are used by surveyors nationally, which the facilities get a copy of, and the ones posted for consumers," Kadonoff explains. The same will hold true once the initiative is implemented nationwide, a CMS source confirms.

"Unfortunately, with this round of consumer reporting, facilities wont be given a resident-level analysis," says Kadonoff. "CMS did mail each facility in the pilot states information about the number of residents MDS records in the numerator and denominator used to calculate their scores," she says. So facilities in the pilot states can use this information in reviewing the MDS records to figure out which residents were included in their percentage scores on the quality measures.

The pilot and national initiative will also allow facilities to gauge their performance against that of their peers nationwide. The American Health Care Association anticipates that "the information will encourage providers to exchange information on new and innovative ways to improve quality," spokesman John Gillan tells Eli.

CMS has tapped state quality improvement organizations to provide technical assistance to facilities that want improve their quality of care. The QIOs (formerly peer review organizations) are working with facilities in the pilot states now and will become integral parts of CMS national initiative.

The flip side of the quality improvement opportunity, of course, is the potential for surveyors to use the new quality measures against facilities.

"Yet, with the exception of the new post acute indicators and pain management, most of the draft measures are in domains that are already measured by the existing QIs," Kadonoff notes. "And hopefully, surveyors will use the new quality measures in the way that the QIs are intended to be used in the survey as a way to focus the survey onsite and never as the sole basis for a citation."

The worst-case scenario: surveyors could use a facilitys performance on the new quality measures to investigate immediate jeopardy on a retroactive basis. "The problem with past IJ is that surveyors usually base it on record review or even facility incident reports," notes Joseph Bianculli, a health care attorney with the Law Offices of Impink & Bianculli in Arlington, VA. "Thus, it is possible that the new data could make the problem worse, but its already bad enough as it is."

Facilities should thus document how, when and why they made any quality improvements in response to the quality measures.