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hen quality indicators were first introduced, many facilities had difficulty making sense of them and their purpose or benefit; almost five years later, facilities are still having difficulty making sense of the quality indicators. As with many processes imposed by the federal government, facilities often try to look for a way to short cut or provide the picture they think will please the survey team or corporate structure to avoid further investigation or penalties. As with other imposed processes, the primary use or intent of the requirement is often overlooked. Such has been the case with quality indicators.
       The primary use of the quality indicator reports was to 1) identify any potential areas of concern to focus quality assurance (QA)/quality improvement (QI) activities and 2) identify and select a resident sample for a QA/QI review. Even though there may be many other uses of the quality indicators, facilities should focus on these two primary uses. They can be excellent tools for identifying processes that need improving or developing and hopefully not as the only measure of quality care.
       Before one can really make “heads or tails” of the quality indicators, one must first understand how the quality indicators are derived. The only source of information used for the quality indicators is the Minimum Data Set (MDS). Depending on the quality indicator report being utilized, specific MDS assessments are utilized. For example, the Facility Quality Indicator Profile is one of the most talked about and utilized quality indicator reports. Only four types of MDS assessments are used to calculate this report. These are the Annual MDS, Significant Change in Status MDS, Significant Correction of Prior Assessment MDS, Significant Correction of Prior Quarterly MDS, and Quarterly MDS. You will note that the admission assessment is not used in calculating this report. The other reports—the Facility Characteristics Report and the Resident Level Summary Report—utilize all types of MDS assessments for their calculation. An important fact to remember is that the assessments must be submitted and accepted into the state database for them to be included in the computer generated state reports.
       There are 24 quality indicators, and three of the 24 are considered to be sentinel events. The three sentinel events are indicator 11 (prevalence of fecal impaction), indicator 15 (prevalence of dehydration), and indicator 24 (low risk prevalence of stage 1–4 pressure ulcers). Sentinel events are considered to be important enough that any sentinel event present at the time of a survey must be considered for inclusion of areas to include in the survey investigation. However, the important thing to remember here is the goal is to not have sentinel events, since most of them are avoidable.
       In order to make sense of the indicators, the facility must first understand the MDS process and the importance of accuracy of the MDS coding. In addition, the facility must understand that once an error is identified, if it impacts a quality indicator, a correction should be made to the MDS through the proper MDS process and submitted as soon as possible to the state. It is important that the facility is always accurately represented in the state database. For example, if the coding is done incorrectly and causes a sentinel event to flag and through investigation the facility finds it was in error, it needs to be corrected as soon as possible and submitted to assure the correct information is present in the state database. This ensures that whenever calculations are done, they are being done accurately and your facility is being accurately represented. This is especially important when it comes to quality measures, as these measures are published for the public to review. The focus of this article will be on the quality indicators, as they can be calculated at any time by most computer systems now available on the market.
       The facility must understand the definitions of the indicators and view them simply as indicators and not automatically as “good” or “bad.” I have had incidences where facility administrators used the quality indicators as a measure of quality care and often as evaluation of staff performance. This is unfortunate, as there can be many variables that contribute to an indicator flagging. For example, just because a resident flags indicator 6 (use of 9 or more medications) does not automatically indicate there is a problem. A resident may require five or six medications just to treat one condition, such as a history of heart disease, and if the resident has more conditions than that, more medications may be necessary to sustain quality life.
       The only way to truly make sense of the quality indicators is to understand what causes the indicator to flag and then investigate. Ask yourself the following questions:
1. If the indicator was risk adjusted, were the items included in the risk adjustment correctly coded on the MDS?
2. Was the additional criteria needed to qualify the indicator correctly coded on the MDS? (For example, for prevalence of behavioral symptoms affecting others, was Section E4 b,c, and d, box A, coded correctly?)
3. Was the condition reflected in the indicator properly identified and documented in the medical record?
4. Was the condition reflected in the indicator properly assessed and care planned?
5. Was the condition reflected in the indicator avoidable?
6. Was the condition reflected in the indicator one that would be anticipated for the type of resident population you have in your facility?
       Quality indicators should be a component but not the only component of your quality assurance activities. For example, if you have a high percentage of residents with decline or late loss of activities of daily living, you may want to review your restorative program procedures and determine how many of the flagged residents have been assessed to see if they could benefit from a restorative program.
       The best way to make sense of the quality indicators is to get back to the basics—focus on what tools you can use to enhance quality care and outcomes. Start by reviewing the Facility Guide For The Nursing Home Quality Indicators developed by the Center for Health Systems Research and Analysis, University of Wisconsin. Even though this was the tool taught and published when quality indicators were first introduced, a thorough review by your staff and quality assurance committees will make much more sense now than it did in the inception.