The information contained herein further enhances the information provided in Section VII of Achieving Substantial Compliance entitled, "Achieving and Maintaining Substantial Compliance." If you are placing this information in your manual, it is suggested you insert it at page 214.

The Center for Health Systems Research and Analysis at the University of Wisconsin originally developed twelve quality domains and thirty accompanying quality indicators for use in the quality based survey process. Since the original creation of the quality indicators, HCFA has recently chosen to revise those indicators.

In their current form, the quality indicators more closely correspond to the MDS and can be more readily used by survey teams to assess quality of care and compliance factors related thereto. In the future, perhaps as early as July, 1999, HCFA will be able to compile information from MDS transmissions, generate reports, and use those compilations and reports as part of the pre- survey preparation process. Initially, these MDS based quality indicator reports will be available only to state survey agencies, however, it is anticipated they will be provided to facilities and also be available for public access via the internet.

As does the OSCAR report(s), these quality indicator reports derived from MDS information will reveal to survey teams facility comparative statistics which will show whether a facility is performing within an industry norm or is aberrant from a norm. Those facilities, or those factors within particular facilities, which are indicated as being outside of industry norms will more likely be targeted for citation. Facility performance which occurs outside of a norm does not necessarily mean that a deficiency citation is automatic, but the chances of citation are substantially increased when these aberrations occur.

The key factor to the prevention of citation is the presence of a sophisticated quality assurance program. Generally speaking, based on recent studies completed by the General Accounting Office, HCFA believes the long term care industry apparently does not comprehend the concept(s) of quality management and does not adequately perform the quality assurance function. It seems most likely that those facilities who continue to dedicate only time for quarterly or monthly quality assurance committee meetings will fall far short of both HCFA compliance expectations and the ability to maintain an ongoing survey compliance. It is becoming clear that in order for facilities to efficiently conduct the quality assurance function so that it not only maintains compliance, but performs those identification and improvement functions inherent in any quality assurance process, facilities must now dedicate more time and resources to quality assurance. Those facilities that have been most successful in implementing quality assurance have designated either part or full time (depending upon facility size) quality assurance coordinators whose roles are exclusively quality assurance oversight. Moreover, the involvement of all facility staff in this process is becoming more critical for success. This success is accomplished only through a commitment by management to facilitate the process and a willingness to commit the necessary time and resources to insure the viability of the quality assurance program.

In order to anticipate possible survey problem areas, facilities must have sophisticated quality assurance programs in place. These programs must now be able to at least minimally use the HCFA quality indicators to monitor and assess staff performance. Moreover, in order to best protect a facility's interest, facilities must now be able to access industry wide comparison information in order to predict those factors the survey teams might identify. Facilities cannot wait to receive the HCFA MDS/quality indicator reports to assess their comparative performance, for by the time these reports become available, chances are a survey will have been conducted.

In order to insure that a facility's quality assurance program is designed adequately to efficiently and effectively perform the functions it now must, it is strongly recommended that facilities seek outside expertise to assist in the formulation or revision and subsequent implementation of their quality assurance systems. Once a facility has an effective program in place, it is further recommended that facilities give strong consideration to participating in some cooperative program that provides a facility with industry comparative statistics. Many of these programs are available, and the Facilitator Program developed by the American Health Care Association is one example. The author does not endorse any program currently available, but does caution that in selecting such a program for facility participation that facilities insure the data base available to the program is sufficient to provide the needed industry comparisons. Programs used in a corporate setting comparing those facilities within the corporation are most likely not widespread or inclusive enough to supply a sufficiently large enough facility sample to provide data comparisons that will mirror HCFA information regarding facility norms.

In revising the University of Wisconsin's original quality indicators, it is important to examine those indicators which have been changed. Some changes may represent only semantics, while others do significantly change the nature of the indicator. Those quality indicators which have been revised are indicated by an asterisk (*). The twelve quality domains and accompanying thirty indicators now are:

Domain 1: Accidents
1. Incidence of fracture.*
2. Prevalence of falls.

Domain 2: Behavioral & Emotional Problems
3. Prevalence of behavior symptoms affecting others.*
4. Prevalence of symptoms of depression.
5. Prevalence of depression without antidepressant therapy.*

Domain 3: Clinical Management
6. Use of 9 or more different medications.*

Domain 4: Cognitive Patterns
7. Onset of cognitive impairment.*

Domain 5: Elimination/Continence
8. Prevalence of bladder or bowel incontinence.
9. Prevalence of occasional or frequent bowel or bladder incontinence without a toileting plan.
10. Prevalence of indwelling catheters.
11. Prevalence of fecal impaction.

Domain 6: Infection Control
12. Prevalence of urinary tract infections.
13. Prevalence of antibiotic/anti-infective use.

Domain 7: Nutrition & Eating
14. Prevalence of weight loss.
15. Prevalence of tube feeding.
16. Prevalence of dehydration.

Domain 8: Physical functioning
17. Prevalence of bedfast residents.
18. Incidence of decline in late loss ADL's.
19. Incidence of decline in range of motion.*
20. Lack of training/skill practice or ROM or mobility dependent residents

Domain 9: Psychotropic Drug Use
21. Prevalence of antipsychotic use in the absence of hallucinations.*
22. Prevalence of antipsychotic daily dose in excess of guidelines.
23. Prevalence of antianxiety/hyptonic use.
24. Prevalence of hypnotic use on 2 or more days in last week.*
25. Prevalence of any long-acting benzodiazepine.*

Domain 10: Quality of Life
26. Prevalence of daily physical restraints.
27. Prevalence of little or no activity.

Domain 11: Sensory Functioning
28. Lack of correction action for sensory or communication problems.

Domain 12: Skin Care
29. Prevalence of stage 1-4 pressure ulcers.
30. Insulin dependent diabetes with no foot care.

These quality domains and indicators were formulated as a means by which to measure those factors considered integral to quality of care. It should be noted that HCFA has authorized through grant study the development of new quality domains and indicators that correspond to those survey factors involved or identified with quality of life. It would logically reason, therefore, that once those quality of life domains and indicators are developed, that domains and indicators would likely be developed for resident behavior and facility practices (see Achieving Substantial Compliance, page 34). Facilities would be judicious to begin to develop their own indicators in these areas in order to best effectuate the quality assurance and improvement process.