This is the third column in the series of five addressing how QIS methods can be used in a QAPI system, by showing the parallels between QIS methods and the Five Elements of QAPI.

By breaking down “Element 3: Feedback, Data Systems, and Monitoring,” the parallels between QAPI and the QIS process are clearly apparent.

As the Centers for Medicare & Medicaid Services (CMS) says about Element 3, “The facility puts in place systems to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others as appropriate.”

While the QIS was designed for surveyors to use as a system for regulatory review, providers are able “to put in place a system to monitor care and services” using identical QIS methods. The six QIS assessments in Stage 1 “draw data from multiple sources,” including resident, family, and staff interviews; resident observations; and chart reviews for the short-and long-stay populations. Thus, feedback systems “actively incorporate inputs” from all those specified for QAPI.

CMS said Element 3 includes “using Performance Indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or targets the facility has established for performance.”

The Quality of Care and Life Indicators (QCLIs), which are rigorously defined in QIS, are “Performance Indicators.” The 80 QCLIs from the various Stage 1 assessments cover “a wide range of care processes and outcomes.” In addition, QIS also includes 21 Performance Indicators from MDS to calculate QCLI rates.

Where facility process Performance Indicators are required, the QIS Mandatory and Triggered Facility Tasks yield Performance Indicators relating to such critical processes as dining services and medication administration, which can be so critical to both quality of care and life.

For QAPI purposes, the “targets” set by the QIS Thresholds for regulatory purposes serve merely as a minimum performance standard.

QAPI appropriately demands that everyone work to perform better than they are, comparing themselves to benchmarks based on other facilities and their own past performances. Such benchmarks are increasingly available in large national databases or through repeated measures in individual facilities using a QIS-based system.

A final part of Element 3 is “tracking, investigating, and monitoring adverse events that must be investigated every time they occur and action plans implemented to prevent recurrences.”

Surveyors use the QIS to identify “adverse events” retrospectively during the survey. However, when used in real time in today’s health information technology systems, the QIS methodology identifies adverse events when they occur.

The Stage 2 Critical Element Pathways structure root-cause analyses can be used as the basis for “action plans.”

Thus, Element 3 is completely aligned with voluntary use of QIS methods by facility staff in a QAPI program.

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