Making the most of quality indicator information

GN Management

Making the Most of Quality Indicator Information Susanne J. Heeschen, RNC, BSN

A

decade after the The driving force behind sucoriginal apcessful problem-solving proval of the and decision-making is Abstract: With quality of care and quality of life National the effective use of as the focus of payers, accreditation bodies, regCase Mix data. Data alone are ulators, customers, and providers alike, the use of Demonstration Project meaningless unless quality indicator data available as part of the case and its subsequent imthey are analyzed mix system presents an opportunity for an effecplementation as a payand turned into tively focused effort toward continuous clinical ment and quality information. quality improvement. With a regular and systemmonitoring system, Information then atic review, analysis, and follow-up process, long-term care (LTC) must be turned providers are able to use quality indicators to providers have begun into knowledge identify and address the areas of most signifito fully experience the from which leadcance to their specific population. And because impact of the effort to ers are able to the system is common to all providers, the ability use Minimum Data Set make decisions and to compare outcomes and bring best practice ef(MDS) information, not take action.1 These forts to light is becoming more readily available. simple principles are only as a basis for classifica(Geriatr Nurs 2000;21:206-9) easily applied to the tion, payment, and care planquality indicators, creating ning but also as key to effective an opportunity to put the efclinical quality monitoring. fort of completing the MDS to adThe road has been long and interestditional use. ing. For those of us practicing in demonstration Managing quality improvement (QI) efforts is best states (Maine, South Dakota, Mississippi, and Kansas), the accomplished within an established QI program that deevolution of the case mix system has presented many chalscribes its mission, structure, and basic elements and lenges and fostered many changes, not the least of which how the use and management of data are integrated into has been the development of a more data-driven approach the problem-solving process. With this basic platform in to quality management. Because the quality indicators orplace, case mix quality indicators can become the key ganize assessment information from the MDS into clinical clinical indicators to which the provider can look for indicator categories, providers have an immediate reposiguidance in areas of concern. tory of highly reliable and verifiable clinical data and imEffective use of case mix quality indicator data remediate access to that data from the Health Care quires a basic understanding of how each indicator is deFinancing Administration (HCFA) website. fined (see Table 1) and how quality indicator data can be In their recent publication, Quality Management analyzed to produce meaningful information. Several Integration in Long-Term Care,1 Maryjane G. Bradley and Nancy R. Thompson identify, as many other authorities on key terms, defined in Table 2, make quality indicators quality management have, that the effective use of data is easier to understand. And the availability of technology at the center of any effective quality management model: is critical. Without computer-generated reporting capabilities, efforts of the magnitude described here would Data ➞ Information ➞ Knowledge ➞ Action be impossible.

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Table 1. Quality Indicators: Defining the Basics (Sample) Domain Accidents

Elimination/ incontinence

Indicator

Description numerator

Universe denominator

Process/ outcome

Risk adjusted

1. Incidence of new fracture

Residents with new fracture on most recent assessment

Residents who did not have fractures on most recent assessment

Outcome

No

2. Prevalence of falls

Residents who had fall on most recent assessment

All residents on most recent assessment

Outcome

No

8. Prevalence of bladder and bowel incontinence

Residents who were frequently incontinent or incontinent on most recent assessment

All residents except: comatose, ostomy, indwelling catheter

Outcome

Yes

9. Prevalence of occasional or frequent bladder incontinence w/o a toileting plan

Residents with a toileting plan on most recent assessment

Residents with frequent or occasional incontinence in either bladder or bowel on most recent assessment

Both

No

Adapted from Karon SL. Nursing home quality indicators: the power of information. LTC Spectrum 1997 June:page numbers and Gill HS. How to make quality indicators work for you. Postacute Care Strategy Report 1999 Oct.

In our organization of 13 LTC facilities, the use of quality indicator data started slowly some years ago when our software vendor developed reports that mirrored those being provided by the state survey agency every 6 months. We, in turn, developed a process of report analysis and record review. This effort was fortuitously timed to coincide with our initial Joint Commission on Accreditation for Healthcare Organizations accreditation preparation activities, which was instrumental in helping us move away from a quality assurance model and toward a more dynamic continuous QI model. That work continues by incorporating the case mix quality indicator (CQI) utilization process into our strategic planning, peer review, and CQI programs. Essentially, because each indicator measures a result of care or a specific occurrence, analyzing quality indicator data provides both facility-level and residentlevel information. The first step, facility-level review, is based on a Facility Quality Indicator Report and brings into focus domains and indicators of potential concern. And because the Facility Quality Indicator Profile provides comparison group percent and percentile rank, a provider can target areas that fall below acceptable thresholds. For example, in the off-site preparation stage of annual survey, surveyors use this report to target indicators that fall into the 75th percentile and above and sentinel events (eg, fecal impaction, dehydration, pressure ulcers-low risk). From this analysis process, a group of indicators emerges as potentially problematic and worthy of further review during the survey. Providers can use the same approach to synchronize their survey preparation and clinical QI efforts. Geriatric Nursing 2000 • Volume 21 • Number 4

The next step is to identify residents from the Resident Level Summary who have triggered in one or more indicator area. This bridge step focuses on the selection of a specific sample with a specific potential care issue. The review of care within the records of this targeted group can provide important information about care processes and clinical practice patterns. Selecting a sample of residents should include the following considerations: • Residents from each unit (care and practice variations may emerge) • Residents with linked indicators (eg, falls, incontinence, and nine or more meds) • Residents with only one indicator, signifying some rehab potential (eg, review of a resident with low risk of incontinence and no other indicator may yield information that could result in the restoration of continence) Each record review should be organized to gather the same information from every record and be based on the facility’s clinical standards (assuming those standards are consistent with acceptable standards of practice and comply with applicable regulations). The record review should include verification of the MDS response(s) that triggered the indicator because inaccurate coding means inaccurate data. In our organization, a record audit document has been developed for each indicator that identifies the core components of care expected to be evidenced in the record. Essentially, the audit is designed to validate documentation of assess207

Use Of Case Mix Quality Indicator Information Opportunities

Table 2. Quality Indicators Key Terms General indicators: Some quality indicators reflect occurrences that would be expected to some degree in a facility, such as incontinence or cognitive tmpairment.

Can help improve survey outcomes Common to all nursing facilities, making best practice initiatives more realistic Effective tool for focusing QI efforts in the clinical domains Helps lead to positive clinical change Reliable and verifiable Uses existing data sources for reporting Challenges Can be intimidating and thus underused if not understood Relies on accuracy of MDS, which can be compromised if staff turnover is high Requires commitment to change in thinking about how quality is measured and monitored Difficult to use without effective technological support and training Can seem overwhelming if added to rather than used instead of other QI management tools

Incidence: Some indicators measure the development of new conditions from one set of assessments to another. They compare previous with current assessment findings. Incidence of decline in late loss activities of daily living is such an indicator. Prevalence: Some indicators measure a point in time for a specific indicator based on the most recent MDS assessment. Prevalence of falls, for example, measures all residents who fell in the past 30 days on the most recent assessment. Risk adjustment: Some indicators incorporate a screen for residents who are more likely to develop a condition and then splits the indicator into high and low risk groups. Sentinel events: Some indicators are expected to happen only rarely, if at all. They are considered to be serious enough to trigger investigation, even when only occurring once. Currently, three areas have been designated sentinel events: fecal impaction, dehydration, and pressure ulcers (low risk). Adapted from Hawryluk M. Quality indicators help focus survey. Provider 1999 Aug.

ment, care planning, implementation, monitoring, and evaluation for the indicator(s) under review. For example, the review of the indicator for elimination involves eight elements: • MDS accurately coded • Continence assessment complete • Voiding schedule/intake and output complete • Bowel function assessment (if applicable) complete • RAP #6 (if applicable) complete • Care plan appropriately reflects assessment • Effect of incontinence on socialization evaluated • Evaluation of effectiveness of care plan present Thus, if 12 residents are at low risk for incontinence with prevalence of occasional incontinence without a toileting plan, a review of at least six records with our standard review instrument may determine that the facility’s continence assessment protocol has not been consistently implemented, resulting in inconsistent management. This information then would be reported to the QI team addressing the issue and a plan developed for retraining and periodic monitoring of records to ensure consistent compliance with the protocol. If the cor-

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rection of the problem is effective, future quality indicator data would reflect a reduction in, if not elimination of, the number of residents who are at low risk for incontinence and occasionally incontinent without a toileting plan. Clearly, the potential uses for quality indicator data are numerous. They can illustrate facility performance relative to the indicators as compared with other providers in the state, identify care areas and specific residents for whom in-depth review is indicated, and serve as data sources for monitoring progress in QI efforts. These data have taken a key role in the annual survey process, making it practicable, for the first time ever, for providers to share the same focus as surveyors based on the same data. And if providers are interested in developing best practice initiatives, quality indicators can serve as the common database for that purpose. The results of effective use of quality indicator data also are numerous. With specific and focused review efforts, facility policies, procedures, and protocols can undergo changes that in turn strengthen clinical program structure. Staff become the beneficiaries of training and education around care areas most pertinent to the populations they serve. QI teams have a rich array of data

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for use in their efforts. Survey performance can improve as providers and surveyors reach beyond compliance to a new focus on quality resident outcomes. But, most importantly, the quality of care to those served can improve continuously—and that has to be a good thing!

BIBLIOGRAPHY Gill HS. How to make quality indicators work for you. Postacute Care Strategy Report 1999 Oct. Hawryluk M. Quality indicators help focus survey. Provider 1999 Aug. Karon SL. Nursing home quality indicators: the power of information. LTC Spectrum 1997 June.

SUSANNE J. HEESCHEN, RNC, BSN, is the director of clinical services for the Sandy River Health System in Portland, Maine.

REFERENCE 1. Bradley MG, Thompson NR. Quality management integration in long-term care. Health Professions Press; 2000.

Copyright © 2000 by Mosby, Inc. 0197-4572/2000/$8.00 + 0

34/1/109576

doi:10.1067/mgn.2000.109576

RESEARCH BRIEF Estrogen Replacement Therapy for Treatment of Mild to Moderate Alzheimer Disease Mulnard RA, Cotman CW, Kawas C, van Dyck CH, Sano M, Doody R, et al. JAMA 2000;283:1007-15. The role of estrogen for treatment and prevention of Alzheimer disease (AD) is controversial. In an effort to determine benefit from unopposed estrogen as a treatment for AD, the researchers in the Alzheimer’s Disease Cooperative Study conducted a randomized, double-blind, placebo-controlled clinical trial at 32 study sites (designated as AD centers by the National Institute on Aging) in the United States between 1995 and 1999. Participants were screened and tested at baseline, treated for 12 months, and followed at 2, 6, 12, and 15 months. The primary outcome measure was the Clinical Global Impression of Change (CGIC); secondary outcome measures included the Mini-Mental State Exam (MMSE), AD Assessment Scale-Cognitive (ADAS-Cog), Clinical Dementia Rating Scale (CDRS), Hamilton Depression Rating Scale (HAM-D), memory scores (Emotional Face Recognition Test, New Dot Test), attention scores (Letter Cancellation, Trail-Making Test A, Digit Symbol), language scores (Category Fluency, Letter Fluency), motor scores (Grooved Pegboard Test, Finger Tapping Test), activities of daily living scores (Blessed Dementia Rating Scale parts 1 and 2, Dependency Scale). One-hundred-twenty women were randomized into one of the three groups (placebo, estrogen 0.65 mg/day, and estrogen 1.25 mg/day). Ninety-seven women completed the study: 32 in the placebo group (seven withdrawals with two adverse events), 35 in the estrogen 0.625 mg/day group (seven withdrawals for the seven adverse events), and 30 in the estrogen 1.25 mg/day group (nine withdrawals including four adverse events). The estrogen groups suffered a total of four deep vein thromboses and two sudden deaths. The women’s age averaged 74 with a range of 56 and 91. Mean MMSE at baseline was 21.1 + 3.3. Analyses revealed no significant differences in CGIC scores for women taking estrogen versus placebo (scores of 5, 6, and 7 represent mild, moderate, and marked worsening, respectively). In fact, 80% of the women taking either dose of estrogen compared with 74% of women taking placebo worsened (CGIC score 5.1 versus 5.0, respectively, P = .43). Analyses of secondary outcome measures revealed only one significant difference—the CDRS showed a worsening among women taking estrogen compared with placebo (P = .01). The researchers concluded that estrogen therapy for 1 year did not prevent or slow disease progression and did not improve global, cognitive, or functional outcomes. Hence, the study does not support estrogen as an AD treatment. The role of estrogen in preventing AD requires further research. This clinical trial was well-designed in terms of randomization, placebo control, and repeated measures. More clarity would have been achieved if the primary focus of the article were on the original aim—to determine whether estrogen improves cognitive status in women with mild to moderate AD. With the MMSE score requirement of 14 to 28 to enter the study, some women with normal MMSE might have been admitted into the study (women with mild dementia attain an MMSE of up to 25), and this inclusion would prevent the depiction of any change. An explanation about the inclusion of such a high MMSE score would be helpful. The inclusion of the many secondary outcome variables suggests a larger number of participants would be needed. If each group included large numbers, the estrogen dosages might have been analyzed separately. Because four episodes of vaginal bleeding occurred, an explanation would have been helpful about how some women without hysterectomies were included in the study. Likewise, the adverse events, including the two sudden deaths, in the estrogen groups warranted an explanation about estrogen and deep vein thromboses and death. Although these occurrences may happen in women of this age, their absence in the placebo group warrants a discussion about actual harm of taking estrogen. In all fairness, this study of a small number of women serves as a beginning effort to understand the relationship between estrogen and AD dementia.

Abstracted by Martha Buffum, RN, DNSc,CS, Associate Chief of Nursing Service for Research VA Medical Center, San Francisco, Calif. doi:10.1067/mgn.2000.109579

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