Validation Report for LTC Quality Indicators

   Evaluating and reporting the quality of healthcare currently provided to American patients is a relatively new trend. Quality Indicators (QI) first appeared in our healthcare delivery system several years ago after multiple government investigations revealed gaps in the quality of care for patients in nursing homes.

Today, QIs are intended to reflect the quality of care delivered or specific outcomes that can be attributed to the care delivered by various healthcare providers. A study (Validation of Long-term and Post-acute Care Quality Indicators¹) commissioned by the Centers for Medicare and Medicaid (CMS), released earlier this year, reports the results of a government-sponsored nursing home QI public reporting pilot begun in April 2002. Researchers reviewed various QIs against medical records and other data in 209 freestanding and hospital-based facilities located in six states: California, Illinois, Missouri, Ohio, Pennsylvania, and Tennessee. The report is available in full text at www.cms.gov.

   Facilities were selected for participation in the study based upon their QI scores from the previous year, their geographic location, and their willingness to participate in the data collection protocols. This onsite field review included 5,758 chronic and post-acute patients at facilities that were generally larger, non-profit, and located in urban areas when compared to other facilities in their state.

   Primary resident-level and facility-level data were collected in each facility. Medical records were reviewed to determine care processes provided to a representative resident sample in 21 quality dimensions, such as physical restraint use, pressure ulcers, and pain. The types of care processes reviewed included: 1) whether comprehensive assessments other than the minimum data sets were performed; 2) whether physicians were notified in a timely manner following a change in resident status; and 3) whether care planning was documented in the record for identified problems. For later comparison to the facility's MDS assessment, research nurses independently assessed a subset of MDS items. Facility-level data collected included responses to an administrative survey of administrators and directors of nursing and observations of the general facility environment.

   The Pressure Ulcer QI quantifies the proportion of at-risk residents in a facility who have pressure ulcers ranging from Stage I through Stage IV. Because a large number of clinical and functional risk factors exist for pressure ulcers (eg, poor nutrition, incontinence, diabetes, and immobility), a number of positive preventive activities and responsive factors were evaluated.

   Generally, preventive activities were related to the handling of at-risk residents and treatment of conditions that contribute to or mitigate pressure ulcer risk. Responsive activities were defined as activities that caregivers take to document, communicate, and attempt to ameliorate pressure ulcers once they have developed. Preventive activities for pressure ulcer prevalence included screening, assessment, and treatment for conditions placing residents at risk for pressure ulcers.

   Researchers found the following data to be associated with lower pressure ulcer prevalence:
  * more frequently scheduled assessments of at-risk or suspicious skin areas
  * routine weekly assessments using a standard protocol for delirium, that would, if present, keep residents bedbound
  * observations on the environmental assessment of residents walking or otherwise out of bed
  * observations on the environmental assessment of caregivers providing assistance to residents with nutritional needs
  * a constructed scale expressing the extent to which a facility manages clinical, psychosocial, and nutritional complications across domains in a manner consistent with high quality care.

   Staffing factors provided additional indirect evidence of preventive activities. For example, staffing items related to pressure ulcer prevalence were: 1) the absence of facility management change and 2) the extent to which a facility did not rely upon "floats" or contracted temporary staff.

   Responsive activities for pressure ulcer prevalence included policies, procedures, or actions taken by caregivers in response to existing or newly detected pressure ulcers. Some of those activities included:
  * a comprehensive pressure ulcer assessment (other than the MDS) documented in the medical record
  * physician assessment of pressure ulcers
  * clear documentation in the medical record that the resident had a pressure-related problem or that the resident's condition had changed relative to pressure ulcers
  * when a change was noted in the medical record, documentation substantiated that this change 1) was evaluated within 72 hours, 2) resulted in a notification to physician or therapist, 3) resulted in a referral to a consultant, and/or 4) resulted in a change in the care plan.

   An additional theme related to pressure ulcers was a measure of how well and to what extent the medical record and care plan corroborated that pressure ulcers were a problem. Researchers concluded that a high level of agreement between the two documents signaled a facility's well-integrated system for problem recognition and treatment implementation. As a final note, researchers concluded that the QI that proved invalid was "Failure to Prevent or Improve Pressure Ulcers" and recommended that CMS discontinue its use.

   These findings serve as a valuable guide for best clinical and documentation practices not only for nursing facilities, but also all other clinical settings. Once again, it demonstrates how regulators, attorneys, and accrediting agencies use all portions of a provider's medical documentation to create a mosaic of the types of actual care provided to the individual patient and the quality of the both the caregiver and the organization providing it.