The information contained herein 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 212.

The Center for Health Systems Research and Analysis at the University of Wisconsin, Madison, was HCFA’s contracted source for the original Quality Indicators under the OBRA quality based survey process. Originally, the Center developed 175 quality indicators which were then reduced to the original thirty. In early 1999, the original thirty quality indicators were revised, but the number of quality indicators remained at thirty. Effective July 1, 1999, twenty four of the revised quality indicators have been selected for inclusion in the Facility Quality Indicator Profile.

The Facility Quality Indicator Profile is a report to be generated from information gleaned from each facility’s transmittal of the MDS form. The twenty four quality indicators included in the Profile are those which directly correlate to information found on the MDS. It should be noted that there is no indication that six of the quality indicators have therefore been deleted, just that those remaining six will not appear as part of the Profile report. The twenty four quality indicators which coincide to MDS information and will be used to comprise the Facility Quality Indicator Profile are:

DOMAIN: ACCIDENTS
1. Incidence of new fractures.
2. Prevalence of falls.

DOMAIN: BEHAVIOR/EMOTIONAL PATTERNS
3. Prevalence of behavioral symptoms affecting others
        High Risk
        Low Risk
4. Prevalence of symptoms of depression.
5. Prevalence of symptoms of depression without antidepressant therapy.

DOMAIN: CLINICAL MANAGEMENT
6. Use of 9 or more different medications.

DOMAIN: COGNITIVE PATTERNS
7. Incidence of cognitive impairment.

DOMAIN: ELIMINATION/INCONTINENCE
8. Prevalence of bladder or bowel incontinence
        High Risk
        Low Risk
9. Prevalence of occasional or frequent bladder or bowel incontinence without a toileting plan
10. Prevalence of indwelling catheter.
11. Prevalence of fecal impaction.***

DOMAIN: INFECTION CONTROL
12. Prevalence of urinary tract infections.

DOMAIN: NUTRITION/EATING
13. Prevalence of weight loss.
14. Prevalence of tube feeding.
15. Prevalence of dehydration.***

DOMAIN: PHYSICAL FUNCTIONING
16. Prevalence of bedfast residents.
17. Incidence of decline in late loss ADL’s.
18. Incidence of decline in ROM.

DOMAIN: PSYCHOTROPIC DRUG USE
19. Prevalence of antipsychotic use, in the absence of psychotic or related conditions
        High Risk
        Low Risk
20. Prevalence of antianxiety/hypnotic use.
21. Prevalence of hypnotic use more than two times in last week.

DOMAIN: QUALITY OF LIFE
22. Prevalence of daily physical restraints.
23. Prevalence of little or no activity.

DOMAIN: SKIN CARE
24. Prevalence of Stage 1-4 pressure ulcers.
        High Risk
        Low Risk***

***Designates a sentinel event

As indicated, these twenty four quality indicators will be those that comprise the Facility Quality Indicator Profile. The Profile report will address the percentage of prevalence of each indicator in each facility and compare these percentages to those which are more industry wide. Initially, the comparison group will be based upon all facilities within a state, but the goal is to establish comparison groups similar to those used in the OSCAR reports (i.e., statewide, regional, nationwide).

The statistics used in the Profile report will be taken from the information a facility transmits on each resident’s MDS. Each quality indicator will be accompanied by five columns of information. Those are (1) the number of residents in the numerator, (2) the number of residents in the denominator, (3) the facility percent, (4) the comparison group percent, and (5) the percentile rank.

The numerator indicates the number of residents that actually have a quality indicator, while the denominator indicates the number of residents who could have a quality indicator. The facility percent is calculated by dividing the numerator by the denominator. Facilities should note that these numbers can and will vary from indicator to indicator. Not all residents may be included as part of a particular indicator. If a facility, therefore, is trying to reconcile its Profile report to total census statistics, a number of quality indicators will not match those numbers.

The interpretation of the statistics found on the Profile report is of critical importance. The Profile reports will be available to survey team members prior to the survey. In fact, these reports will now be reviewed by the surveyors as part of the pre-survey review process (see Manual Section I, "The Surveys"). By conducting such reviews, survey team members can and will target certain areas of deficient practice which the Profile identifies. The Profile reports will also be available to facilities. Facilities will be able to access their Profile reports via the same mechanism through which they transmit the MDS. Each facility should receive specific instructions as to how to access these report(s). A facility’s success in the survey process will greatly depend upon its ability to interpret the statistics on the Profile report and address those areas which are likely to warrant further investigation by the survey team.

Each quality indicator will have a facility percent, calculated as discussed previously. Unlike the achievement tests taken in school, the percentile rank assigned to a facility’s quality indicator is the inverse of its severity of concern. While the achievement test identifies those in the 90th percentile as high achievers (better than all but ten per cent of the population), the Profile report’s labeling is just the opposite. Facilities identified in the 90th percentile would be those identified as worse than all but ten per cent of facilities.

HCFA has established an arbitrary threshold level for all quality indicators, as well as classifying those which may be considered outliers. The threshold level for all quality indicators will the 75th percentile. Any facility indicator at the 75th percentile or worse (above) will be identified by the survey team has having the likelihood to warrant further review. Outliers are defined by HCFA as those quality indicators which represent an extreme condition and indicates a facility lies outside the peer facilities in its comparison group. While no specific parameters to define outliers have been determined, facilities should expect that percentiles at the 95th level or higher, or the 5th level or lower will be considered outliers and possibly warrant further review.

An example might serve to further illustrate how the Facility Quality Indicator Profile report will reflect certain quality indicators and statistics. For hypothetical purposes, assume a facility with the following characteristics:

               SKIN CARE

               Census: 100
               Prevalence of Pressure Ulcers: 20
               High Risk: 18 out of 80
               Low Risk: 2 out of 20

In calculating the percentages for the Profile report, some of the quality indicators are risk adjusted. By doing so, only those residents that are identified as belonging within a certain indicator are placed there. In that regard, a facility cannot always reconcile Profile report statistics to the census.

While this hypothetical facility has a facility percent of 20 for the prevalence of pressure ulcers (the numerator 20 divided by the census denominator of 100), its percent of pressure ulcers in that population it has identified as high risk is 22.5 (the numerator 18 divided by the denominator 80, or those identified on the MDS as high risk). Moreover, the percent of pressure ulcers in its low risk population is 10 (the numerator 2 divided by the denominator 20, or those identified on the MDS as low risk).

For hypothetical purposes further assume that the comparison group statistics for the same quality indicators reveal these percent(s):

When a facility receives its profile report, it should scrutinize the percentile rank column for comparison purposes. For continuing purposes of this hypothetical, assume the following percentile ranking:

Appearing on the actual Profile report will be flags designating those percentile ranks for which the surveyors should warrant further review. In our hypothetical, two flags would appear on the Profile report. One would appear adjacent to the prevalence of pressure ulcers in the facility for the percentile of 82 exceeds the HCFA threshold of 75. Another flag would appear adjacent to the low risk percentile because the presence of a pressure ulcer in a low risk resident is a sentinel event. While the high risk percentile would not be flagged because it is less that 75, chances are this facility’s skin care program would be closely reviewed by the survey team.

In addition to the Facility Quality Indicator Report, the MDS transmittal information will also generate two other reports for surveyor and facility review. One is the Facility Characteristics report. This report contains statistical information about a facility and compares those statistics to the comparison group by using percentages. For example, the Characteristics report might reveal that a specific facility resident population is comprised of 82% female, while the comparison group shows 75%. The numbers on these reports may not always total 100% due to missing data because they are based upon all MDS information excluding the admission MDS. There are no expectations or thresholds that are assigned to the characteristics report, but facilities should become aware of how to use the Characteristics report to protect their best interests if possible or applicable.

For example, a facility may have a high incidence of antipsychotic drug use that places it beyond the acceptable threshold. This would flag that quality indicator and cause the survey team to investigate facility procedures and protocols regarding the use of antipsychotics, as well as reviewing residents for adverse drug reactions and unnecessary drugs. If, however, the facility characteristics report revealed that the facility has a population with a high percentage of psychiatric diagnoses, that might provide justification for the high threshold in antipsychotic drug use and minimize the extent to which the survey team investigates that particular quality indicator. Additionally, a facility’s OSCAR reports can also be used to justify flagged thresholds (see Section VIII, "Using the OSCAR").

The third report that the MDS transmittal information generates is the Resident Level Summary report. The Summary report reflects information on each facility resident and indicates whether a resident’s MDS information indicates the presence of a quality indicator. The summary report indicates the date of the most recent assessment, indicates the type of assessment (quarterly, full assessment, etc.), then provides a checked indication as to whether the resident’s MDS has identified a quality indicator for that resident. The Summary report is resident specific and does not provide facility based statistics. This report will reveal those residents with a higher number of quality indicators present and will be used by the survey team to assist in identifying those residents that will be selected to be used in survey resident samples (see Manual Section I, "The Surveys).