It is correct to assume that faithfully replicating the QIS may lead to identifying “deficient practice,” but to improve care requires going beyond what is contained in the QIS forms.

In fact, the way you implement the QIS methods to improve care is very different than the way surveyors conduct the QIS.

Rather than replicating a one-time quality survey, administrators need to use the QIS methods in performance improvement cycles.

To do this, administrators should conduct quarterly cycles, beginning each one by drawing a random sample of 40 residents residing in the building and a random sample of 30 admissions from the past six months or however far back is needed to obtain 30 admissions.

In the first month of the quarterly cycle, conduct the Stage 1 assessments on these residents.

While there are some situations that you will want to look into and correct immediately while conducting assessments, such as allegations of abuse, do not try to correct everything you identify from these assessments while you are conducting them.

Rather, compile the findings from all assessments for the sample of residents and then generate reports based on these Stage 1 data, preferably using an automated system.

If properly calculated, you will then have rates at which different types of potential quality problems occurred.

Using the Stage 2 QIS forms can help determine the root cause of the potential problems you have identified, as well as inform you how surveyors will determine if the identified potential problem is considered to be deficient practice. But there is a more challenging task: improving the care you provide.

This requires you first to change something, and then to assess again—completing the cycle.

The first step in correcting the problem is developing a better understanding of the findings. Is this a problem related to a single resident that occurs rarely, such as a fall with a fracture? Or is it a more pervasive issue, such as residents not being treated with dignity by a particular staff member or several staff members? Or is it a widespread issue such as not offering residents preferences on when and how often they receive a bath or shower?

All of these are important, and none are easy to resolve. Each administrator must approach each problem as if it is not a single incident, or multiple unrelated incidents, but rather a breakdown in the care process.

People often want to blame an individual staff person, but quality problems are more often than not system or organizational culture problems, which is why resolving them takes thoughtful analysis and then a solution that works for all concerned.

Once you think you have identified and implemented a solution, then you must reassess using new samples to ensure that you were successful in improving care. Only then have you completed the cycle.

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).