QIS Training

1. QIS
Information to Support States
Preparing for QIS
Training and Implementation
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2. Agenda
 Welcome and Introductions
 Background and Overview of QIS
 QIS – Continuous Quality Improvement
 State Roles and Responsibilities in
Training Process
 Description and Timing of QIS Training
 Questions
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3. 3
What is the QIS?
 Approved Federal nursing home survey
process to increase consistency,
reliability and accuracy
 Uses customized software on tablet
PCs to guide surveyors through a two-
staged systematic review of the
regulatory requirements

4. 4
QIS Development
 Produce prototype (1998 – 2005)
 Demonstration and Evaluation (2005 – 2007)
– Two teams each in: KS, OH, CA, CT, LA
 Develop and refine national training model (2006
2007)
– Three States: FL, CT, KS
 National implementation State-by-State to replace
Traditional survey (2007 – present)

5. What Does the QIS Provide?
 Structured approach to achieve more
accurate and consistent results
 Larger and more diverse randomly
selected samples to obtain a more
accurate picture of the residents
 Automation to systematically review
regulatory areas, synthesize surveyor
findings, enhance investigative
protocols, and organize surveyor
documentation
5

6. What QIS Is Not
QIS Does Not Represent:
 Change in Social Security Act
 Change in the Regulations
 Change in Interpretive Guidance
 Change in enforcement process
6

7. Comparison of QIS and
Traditional Survey Process
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8. Automation
Traditional
Information recorded on
paper throughout
process; computers are
used for Statement of
Deficiencies (CMS-
2567)
QIS
Each team member
uses a tablet PC to
document findings
throughout the process;
findings are
synthesized, organized,
and loaded to the CMS-
2567 by the software
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9. Offsite Preparation
Traditional
 Review:
OSCAR 3 and 4
Reports
QM/QI Reports
Results of
complaint
investigations
 Pre-select a sample
based on above
QIS
 Review:
OSCAR 3 Report
Uninvestigated
complaints
 Random selection of
Stage 1 samples from
MDS data loaded onto
tablet PCs
9

10. Onsite Preparation
Traditional
 Roster/Sample Matrix –
Form CMS-802
QIS
 Alphabetical resident
census with room
numbers/units
 List of new admissions
over last 30 days
10

11. Initial Tour
Traditional
 Gather information
about pre-selected
residents and identify
new concerns
 Determine whether
pre-selected residents
are still appropriate
QIS
 Brief overall
impression of the
facility, the residents,
and the staff
 Not intended for
sample selection or
supplementation
11

12. Sample Selection
Traditional
 Sample size determined
by facility census
 Residents selected
based on QM/QI
percentiles and issues
identified offsite and on
the initial tour
QIS
 Stage 1 sample size:
Admission (30)
Census (40)
 Stage 2 sample size
based on number of
triggered care areas
 Residents selected by
software
 Surveyor-initiated
sample
12

13. Survey Structure
Traditional
 Phase I: focused
& comprehensive
reviews
 Phase II: focused
reviews
QIS
 Stage 1:
preliminary
investigation
 Stage 2: in-depth
investigation of
triggered concerns
from Stage 1
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14. 14
Two Stages of QIS
Stage 1: Preliminary investigation of
regulatory areas to determine resident
care areas and facility practices for
Stage 2 investigation
Stage 2: In-depth investigation to
determine whether deficient practice
exists, document deficiencies, and
determine severity and scope

15. 15
Three Steps in Each Stage
1. Sampling (computer-generated)
2. Investigation
3. Synthesis

16. 16
QIS Stage 1
 Sampling – Random census (40) and
admission (30) samples
 Investigation – Structured resident, family,
and staff interviews; resident observations;
chart reviews
 Synthesis – 128 resident-centered and 34
facility-level Quality of Care and Quality of
Life Indicators (QCLIs) to identify care areas
that exceed national thresholds

17. 17
Stage 1 Triggers for Stage 2
Investigations

18. 18
Surveyor-Initiated Sample
Surveyors can initiate an investigation of
care areas for any resident or of facility
tasks. Because of the large QIS samples,
surveyor-initiated investigations are a
small part of the process.

19. 19
QIS Facility Tasks
 Completed on every survey
– Liability Notices & Beneficiary Appeal Rights Review
– Dining Observations
– Infection Control and Immunizations
– Kitchen/Food Services
– Medication Administration and Drug Storage
– QAA
– Resident Council President Interview
 Completed if triggered
– Abuse Prohibition Review
– Admission, Transfer, and Discharge Review
– Environmental Observations
– Personal Funds Review
– Sufficient Nursing Staff Review

20. 20
QIS Stage 2
 Sampling – Three residents per triggered
Care Area plus surveyor-initiated residents
(e.g., complaints)
 Investigation – Specific or general Critical
Element pathway or facility task pathway and
interpretive guidelines
 Synthesis – Determine compliance with each
Critical Element, document noncompliance at
the applicable F tags, determine severity and
scope

21. QIS Satellite Broadcast:
http://surveyortraining.cms.hhs.gov/pubs/VideoInformati
on.aspx?cid=1082
QIS Resource Manual:
http://www.uchsc.edu/hcpr/qis_manual.php
QIS Electronic Forms and Worksheets:
http://www.uchsc.edu/hcpr/qis_forms.php
QIS Brochure:
http://www.cms.gov/SurveyCertificationGenInfo/downlo
ads/SCLetter08-21.pdf
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21
Additional Information

22. QIS – Quality Improvement
CMS-Federal Monitoring of the QIS
 RO surveyors trained in QIS process
 Desk Audit Reports
DAR-SA for State
DAR-RO for CMS Regional Office
 Federal Oversight of the QIS (FOQIS)
 QIS Comparative Survey
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23. 23
QIS - Quality Improvement
Desk Audit Report (DAR)
a management tool which can be used by:
 The CMS CO for ongoing monitoring of
QIS consistency across Regions Offices
(RO) and States (SA);
 The RO’s for Federal Oversight of the QIS
process (FOQIS); and
 The SA’s for monitoring districts, teams
and individual surveyors

24. RO & SA use of the DAR
 Reviews results;
 Raises questions;
 Investigates outcomes;
 Assists the RO & SA with
oversight/training; and
 Can direct SA monitoring
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25. 25
Timeline
 CU sends 6 DAR-SAs with clinical analysis
and a call to discuss each
 CU sends 3 DAR-SAs with clinical analysis
and no call
 SA receives clinical analysis training
 CU and SA comparison for one DAR-SA
 SA assumes responsibility of analyzing
DAR-SAs

26. Goal of QIS Data
Identify and address sources of
inconsistency:
Implementing the QIS process
accurately
Conducting adequate and thorough
investigations and making accurate
compliance decisions
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27. DAR-SA Review
1. Throughout each quarter, SA reviews
multiple DAR-SAs
– Identify and analyze outliers/trends
– Determine root cause
– Implement training, monitoring or
corrective action as appropriate
– Monitor effectiveness
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28. DAR-RO Review
2. At the end of the quarter, RO and SA
receives State-Specific DAR-RO
3. RO conducts QI call within 4 weeks (not
fully implemented)
4. Onsite FOQIS is conducted using a
targeted, data-driven approach (not fully
implemented)
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29. Preparing for Successful QIS Training
and Implementation
Review CMS Issued Documents
 Fiscal Year State Survey & Certification Budget Letter
(Mandatory Requirements - equipment and encryption)
 State Operations Manual, Appendix P
 QIS Training Process - State Operations Manual, Chapter 4
 National Implementation Priority Order (S&C 09-50)
 QIS Satellite Broadcast:
http://surveyortraining.cms.hhs.gov/pubs/VideoInformation.aspx?cid=1
082
 QIS Brochure:
http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter0
8-21.pdf
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30. Preparing for Successful QIS
Training and Implementation
 Informing State management about QIS
 Identifying QIS management and teams
 Educating stakeholders in the State
 Begin logistics preparation for initial QIS
classroom training
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31. Preparing State Management Team
for QIS
 Kick off call with State, CMS, and NHQ
 Orient and educate managers/supervisors about
QIS, the training process and
 State develops QIS training plan
 Identify a QIS State Lead
 Identify a QIS IT Lead
 Identify 8 surveyors to participate in initial/core QIS
Classroom Training
 Identify additional support staff to help with
preparatory logistics for QIS training
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32. Role of QIS State Lead
 Able to make supervisory decisions and provide oversight
 Support the QIS process
 Participate in QIS training, classroom and field
 Achieve mastery of the QIS
 Manage potential challenges from nursing homes
 Serve as the point of contact for the State Agency for
discussion with CMS and/or its contractors
 Educate provider and consumer organizations
 Collaborate in the planning and preparatory activities with
the training contractor
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33. Role of QIS State IT Lead
 First line of contact for surveyors to address and resolve
software issues using the QIS process and QIS software
 Successfully completes ASPEN Technical Training
 Experienced and proficient with all ASPEN suite of products
 Creating survey shells in ACO
 Assisting staff with uploading surveys from ASE to ACO
 Participates in both classroom and onsite QIS training
 Able to train additional staff on the technical aspects of the
QIS process
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34. QIS Core Group of Surveyors
 State identifies eight surveyors (2 teams of
4) to participate in initial round (core) of
QIS training
 Minimum of two years of recent LTC survey experience
 SMQT qualified
 Possess intermediate computer skills
 Prior teaching or training experience, if possible
 State selects four QIS trainer candidates from
initial core group of surveyors trained in QIS
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35. Educating Stakeholders on QIS &
State’s Implementation Plan
 Dedicate a section of State Web site for QIS
information and resources for stakeholders
 Schedule, announce and participate in “Overview
of QIS for Stakeholders” with CMS and NHQ
 Communicate with stakeholders regarding the QIS
process and the QIS implementation in the State
on an ongoing basis
 Stakeholder education is key to successfully
implementing QIS
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36. Preparatory Logistics and Tasks for
Core Group QIS Training
 QIS Classroom Logistics Checklist call with NHQ
 QIS IT Logistics Checklist call with NHQ
 Schedule 1-Day IT Training led by Alpine Technology Group
for State’s IT staff
 Secure all necessary equipment for QIS training
 Determine classroom location and nursing homes for mock
(simulated training)survey and surveys of record
 Load and test participant tablets PCs with QIS software/files
 State led computer orientation training for surveyors
participating in QIS training
*Please refer to the QIS Training Timeline document and QIS Classroom
Logistics Checklist for a detailed list of logistics
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37. QIS Classroom Training
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38. Training Requirements
for Registered QIS Surveyor
 Prerequisites
Proficiency with tablet PC functions and
computer skills
 Completion of classroom training
 Participation in mock training survey
 Participation in surveys of record with successful
compliance assessment
 Documentation in CMS Learning Management System
(LMS)

39. 39
Initial (Core) QIS Training
Example

40. QIS Train-the-Trainer (T3)
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41. Training Requirements for
CMS-Certified QIS Trainer
 Be Registered QIS Surveyor
 Successfully complete additional requirements
Complete at least six QIS surveys of record
Attend Train the Trainer workshop
Provide the QIS classroom training
Monitor surveyor-students in mock survey
Conduct compliance assessment for surveyor-
students during a survey of record
Remain actively involved in QIS training/surveys
 Documentation in CMS Learning Management System
(LMS)

42. 42
QIS Train-the-Trainer (T3) Schedule
Example

43. Tips for a Smooth QIS Training
 Provide a comfortable classroom learning environment and furnish
required equipment
 Educate State management about QIS
 Supervisors participate in training
 Recognize the learning curve and additional time needed to
complete QIS (Plan on a minimum of 40 in-facility hours per
surveyor per week)
 To the degree possible, select facilities for the mock & surveys of
record that do not have a history of serious care issues and
consider commute time for surveyors
 Avoid adding tasks such as licensure review to QIS surveys during
initial QIS training activities
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