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 The QIS Expert

Why The Deficiency Variation Among Facilities?

 Dr. Kramer is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey (QIS).

Q.  If the QIS is supposed to be more consistent, why do we observe such a wide variation in The number of deficiencies?

A.  The answer has to do with what is meant by a “more consistent” survey process. More consistent in this regard has two meanings. First, with QIS we would expect that what surveyors actually do when they are on site in the survey will be the same across states, districts, and surveyors. Important details such as how they sample residents, how they conduct interviews with residents and families, and how they make observations of residents are more consistent in QIS.
For example, the Stage 1 samples are larger and randomly selected so they are not based on prior survey results. This ensures that resident samples are selected in the same way by all surveyors and without a focus on preconceived concerns about quality that surveyors may have based on prior surveys.
Each annual survey is an independent event, so if a facility has changed appreciably since the last survey—either by improving or declining in quality—then the surveyors are not biased by previous survey results. Stage 2 investigations also follow a more sequential and structured process, leading to a more systematic investigation process.
The second meaning of more consistent relates to survey outcomes. Consistency in this regard means that if two different teams from different districts or states conducted a survey of the same building at the same time, then they would get the same result. The more consistent QIS process clearly helps to ensure that this occurs, but it also requires consistent decision making. Greater consistency is addressed by the rigorous surveyor training and review during training, as well as monitoring by the state agency using the QIS data in a procedure.
What consistency in the survey does not mean is that surveys in all states, or districts, or buildings, will get the same number of deficiencies. For this to happen, it would mean that all the nursing facilities have the exact same level of quality—which is not the case. A different quality standard was in place over an extended period of time because the traditional survey was not consistent across teams, districts, and states. Providers naturally adapted to each local standard.
So replacing this inconsistent standard with a consistent standard should result in a wide variation in the number of deficiencies across states, districts, and facilities.
Many facilities that formerly had good or moderate survey results have worse results with the more comprehensive QIS. A fair number of homes have better results on QIS, particularly if they are very oriented to quality of life.
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