A Practical Way to Use the Quality Indicators in Long-Term Care

by Pam Manion, RN, GCNS
Katy Nguyen, RN
Carol Siem, RN, GNP
Clara Boland, RN, PhD
MU Sinclair School of Nursing
University of Missouri-Columbia

Mary Zwygart-Stauffacher, PhD, GNP
University of Wisconsin-Eau Claire

Marilyn Rantz, RN, PhD
MU Sinclair School of Nursing
MU School of Medicine
University of Missouri-Columbia

The recent national rollout of nursing home quality indicator (QI) data was generally well received, although various stakeholders have acknowledged that the general public need help in interpreting this information (see "Quality of Care or Quality of Life--What Really Tells the Story?", "The Quality Dilemma: A Continuing Challenge for LTC Leaders," and "National Nursing Home Quality Data Release Generally Applauded," as well as "Making Sense of the Quality Indicator Data Patient & Family Concerns" on p. 3 of the January 2003 issue of Caring, and www.amda.com/consumers). At the same time, many nursing home administrators and staff are not taking full advantage of the insights that the Minimum Data Set (MDS)-derived QIs can provide.

All QIs are worth close examination because they are not just numbers; they reflect the clinical problems experienced by the residents. Some of the problems identified by QIs are avoidable, while others may occur as a natural consequence of increasing illness and frailty.

This article is intended to help nurses and other health care providers working in long-term care facilities to use QIs in an organized manner, thus improving care processes and residents' outcomes. It may also provide information that can be used in patient and family education about QIs and their relevance to care assessment.

QIs: The Basics

QIs are markers that may indicate the presence or absence of potentially poor or good care practices (Zimmerman et al., 1995) by measuring processes and outcomes that are derived from MDS data (Karon, Sainfort, & Zimmerman, 1996). The Center for Health Systems Research and Analysis (CHSRA) at the University of Wisconsin developed the QIs, and 24 of them have been reported to facilities nationwide for their use since 1999.

The CHSRA QIs were primarily designed for use in the state and federal survey process. However, the CHSRA QIs (see box, right) can also be useful tools for quality improvement.

Facility-specific CHSRA QI reports are available via a federal computer network. The QI report displays five columns for each indicator. The numerator is the actual number of residents who "had" the problem defined by the QI. The denominator is the number of facility residents who potentially could have had the problem defined by the QI. Both numerator and denominator are determined by specific MDS items that are identified in the Facility Guide for Nursing Home Quality Indicators (CHSRA, 1999).

The facility percent represents the percent of residents in the facility that had the problem defined by the QI. The numerator divided by denominator equals the facility percent.

The comparison group percent is the statewide average QI score. The percentile rank provides information about where the facility ranks among all other facilities in the state for a QI score. High percentile rank scores indicate a high likelihood of care problems in the facility (CHSRA, 1999; Zimmerman et al, 1995).

Among the care domains, the QI report identifies three sentinel events (QI #11-Prevalence of fecal impaction, QI #15-Prevalence of dehydration; and QI #24-Prevalence of pressure ulcers in the low-risk population). These QIs indicate undesirable, serious, and often avoidable processes or outcomes. Sentinel events should occur infrequently and should always trigger further analysis and investigation (CHSRA, 1999).

Although a primary use of the QI reports by nursing facilities is to identify and review any areas of care that point to potential problems as staff prepare for survey, the reports are also useful for quality improvement. However, when using the CHSRA QI report as a tool for quality improvement, one of the items--"comparison group percent"--is somewhat troubling.

The comparison group percent is the state's average score for the QI. When averages are used to compare organizations, the following questions must be asked, "What does an average mean? Is an average an indication that things are good?" Facilities may end up using the average as a benchmark for quality-improvement efforts and stop attempting to improve care practices because they believe they are performing better than average (Rantz et al., 1997, 2000).

In reality, however, the state average might reflect a statewide problem. If the average score is seen as "good," facilities may choose not to evaluate and change poor clinical practice.

Show-Me QI Report

Under a cooperative agreement with the Missouri Division of Aging (now the Missouri Department of Health and Senior Services), we and our colleagues have developed the "Show-Me QI Report," a different type of QI report based on the principles of continuous quality improvement. Missouri's Show-Me QI Report is presented in a format that allows easy recognition of potential care problems. Data are linked for five quarters of MDS submissions and displayed in both graphic and table format so that facilities can readily interpret their own trend lines (Rantz et al., 1997, 2000). These reports are available to Missouri facilities via a computer network (see a sample report, in pdf format, at www.nursinghomehelp.org/sampleqi.pdf).

The CHSRA QI reports use percentile rank scores to identify potential problems, whereas the Show-Me QI Reports use absolute thresholds to identify scores that may indicate care problems. These thresholds were set for each QI using an expert-panel approach. For further discussion about using thresholds, refer to the MU MDS and Quality Research Team's published work on the topic (Rantz, et al., 1997, 2000, in press) and their Web site: www.nursinghomehelp.org.

Facilities in Missouri have found the Show-Me QI Reports to be helpful. Some differences between the Show-Me QI Report and the CHSRA QI reports are that Show-Me QI Reports present longitudinally linked data points, use absolute thresholds, and visually illustrate a facility's trends--progress, constancy, or decline (Popejoy et al., 2000, Rantz et al., 1999, 2001). The strength of this report is that it provides a 15-month trend, helping nursing home staff recognize and analyze problems and concerns in a systematic manner, and identify how the systems or programs should be changed to improve.

However, according to Rantz and colleagues (2000), a limitation of this report is that it is only available to Missouri. Other states have indicated an interest in making reports modeled after the Show- Me QI Reports available.

QI Analysis

It is important to remember that neither the CHSRA nor Missouri's Show Me QI reports provide evidence that low or high scores are absolute indicators of good or poor quality. Furthermore, the presence of problem conditions does not always indicate that that poor care was given. Although problem conditions may not always be avoidable, they can often be managed so that the effect on quality of care and quality of life is minimized. Thus, it can be helpful for facility staff to have additional information that helps them define the scope of a potential problem.

Effective QI analysis can provide this information. Facility staff need to ask, "is this a one-time problem or has this problem been on-going for some time?" It is not unusual for facilities to have multiple QI scores that are high. Facility staff are then faced with the question, "Where do I start?"

Trending of data over time helps staff make these difficult decisions. High QI scores may point out problems in resident assessment, care delivery systems, or staff training. Sometimes a high score may not indicate a problem, but rather reflect the needs of the facility's resident population. For example,QI #6 (use of 9 or more different medications) may be high. However, if those medications were reviewed by a pharmacist, physician, and nurse, found to be reasonable, and the clinical reasoning of the clinical team is documented, the high QI score is not a problem. If the residents are not experiencing negative outcomes as a result of the use of 9 or more different medications, the high QI score is not a problem.

QIs for Quality Improvement: An Example

Following is an example of how QIs can be used for quality improvement, using the CHSRA QI Report and the Show-Me Report.

The Administrator and DON of the "Aplus LTC Facility" are meeting to discuss family satisfaction survey results. They notice a significant number of responses that indicate concern about the "smell of urine throughout the facility." The issue is taken to the Quality Improvement Committee, a small group of nurses, certified nursing assistants (CNAs), and other facility staff.

The committee reviews the CHSRA QI Report, focusing on the percentile ranks for QI #8 (Prevalence of bladder and bowel incontinence) and QI #9 (Prevalence of occasional and frequent bladder or bowel incontinence without a toileting plan). They find that the facility scored in the 68th percentile for QI #8 and the 17th percentile for QI #9. Since these rankings are below the level of the statewide average and are below the 75th percentile, which would trigger surveyor interest, the team is not sure if there is a problem.

Aplus LTC Facility is located in Missouri, so the committee turns to its Show-Me QI Report. In this report, their scores for both QI #8 and #9 were in an acceptable range for the first three quarters, but scores were trending upward over the upper threshold in the past two quarters. This information tells the committee that the facility had been doing well in these areas previously, but the upward trend indicates some sort of problem in the past six months.

Aplus LTC Facility has a policy that all residents are to be toileted on a routine basis unless another type of plan has been developed based on assessment. This information is included in the orientation for new nurses and CNAs. The quality improvement committee notes that the in-service coordinator quit suddenly eight months ago and orientation has been handled by the assistant director of nursing since that time. There has also been high turnover among CNA staff in the past few months. They wonder if the cause of this problem could be lack of education.

Their next step is to measure performance. They review the care of the residents who are positive for the QIs by using the report's resident roster. According to Aplus LTC Facility's policy, residents who are incontinent should have had a comprehensive assessment looking for possible environmental, functional, and physiological reasons for incontinence.

Next, they look for the answers to these questions:

1. Has the incontinence assessment actually been done?
2. Does the resident have a toileting plan identified?
3. Does the care plan reflect that toileting plan?
4. How is this plan communicated to direct care staff?
5. Are staff members aware of the plan?
6. Are staff actually toileting residents per their care plan?
7. Are staff aware of the facility policy?
8. Is there a particular unit or shift that is problematic?

Once the team has answers to these questions, the next step is performance improvement. If toileting is not occurring as planned or expected it is necessary to establish why not. The quality improvement team would then talk to the staff responsible for care and, using a team approach, work with them to identify barriers to getting the work done.

The following questions frame the discussion:

1. Is this a problem with systems or with employees?
2. Is there a need for staff education and training?
3. Is inadequate staffing the problem?
4. Is there adequate communication of the plan of care to the direct care provider?
5. Is there follow up by team leaders about their expectations of the work to be done?
6. Are staff members aware of the policies?
7. If they are aware but do not provide the care, is counseling needed for clarification of job expectations?
8. What changes need to occur in order for the work to be done?

Based on the problems identified, the team, which included direct care staff, developed a plan to address the clinical problem. The team reviewed their systems, observed care being provided, and identified that incontinence assessments had not been completed in recent months. They also found that care plans did not indicate toileting plans. CNAs were not aware that residents were to be toileted. A routine of "check and change incontinence briefs" had become the standard approach with all residents, regardless of the resident's capacity to remain or regain continence.

Plans to address those deficits were developed and put into action. The team took steps to educate the staff and make sure assessments and care plans were developed. After these changes are made, the team will need to review care at intervals to make sure the expected changes in care delivery have actually occurred.

The team will also examine the incontinence QIs to be sure the expected outcome occurred. If not, they will go back to the drawing board and develop a new action plan. If the expected outcome did occur, that is, toileting practices improved as did incontinence QIs, monitoring must continue to assure that staff are able to maintain the desired outcomes.

Aplus LTC Facility followed these basic steps as they identified a problem and developed a plan to correct the problem:

1. Recognize there is a potential clinical problem. Initiate a review of appropriate QIs and determine if they reflect a potential problem.
2. Using a team approach, review the care of specific residents.Look at policies and procedures. Watch the care being delivered. Consider systems failures, not just potential employee failures.
3. Identify whether there is or is not a problem.
4. Identify which pieces of the process to change. Develop an action plan based on suspected causes.
5. Implement the plan. Make the planned change in a small trial group.
6. Review care to determine if the action plan was effective. If the change was effective, make the change throughout the facility. If the change was not effective, begin the problem-solving process again.
7. After implementing the change throughout the facility, go back and watch the care to be sure the practices are changed. If they are not, explore why not and begin the problem-solving process again.

Conclusion

For true and lasting changes to occur within an individual facility or a corporate structure, a systematic approach needs to exist that allows for the thoughtful and systematic management of resident care. QIs offer valuable insight into clinical problems and, if regularly analyzed and used for quality-improvement purposes, facilities can use these tools to address clinical problems within their organizations.

Acknowledgements

The authors wish to acknowledge the contribution of other University of Missouri-Columbia MDS and Nursing Home Quality Research Team and other Quality Improvement Nurses, including former research nurse Lori Popejoy, and the support of the Missouri Department of Health and Senior Services staff. Activities were partially supported by a cooperative agreement with the Missouri Department of Health and Senior Services and the Sinclair School of Nursing and Biostatistics Group of the School of Medicine, University of Missouri-Columbia , Contract #C-5-31167. Funds from the Missouri Department of Health and Senior Services included partial support from the Centers for Medicare and Medicaid Services.

The opinions expressed are those of the authors and do not represent the Missouri Department of Health and Senior Services or the Centers for Medicare and Medicaid Services.

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