Zimmerman: MDS QIs

The MDS QI’s:  A Potential Resource for Consumers in Monitoring Care

David R. Zimmerman, Ph.D.

Center for Health Systems Research and Analysis

University of Wisconsin-Madison

There is general agreement that in order to assure and improve quality of care, it is necessary to have the commitment and involvement of three important groups:  (1) the regulatory agencies, responsible for the external review of quality; (2) the provider community, which must exhibit a strong commitment to providing and improving quality of care: and (3) the consumers of care, who must be well informed in selecting providers and vigilant in monitoring care once they and/or their loved ones are in the long term care system.  Many of the quality assurance activities in the past few years have focused on the first two groups, but there has been much less attention devoted to providing consumers with the tools they need to monitor care.

The emergence of the Minimum Data Set (MDS) as a standardized instrument to assess the health and functional status of nursing home residents represents an important step in rectifying this situation.  Indicators of quality of care can be found in the MDS, providing an important tool for consumers.

The MDS Quality Indicators 

Over the past several years, researchers at the Center for Health Systems Research and Analysis (CHSRA), University of Wisconsin-Madison, have developed and tested a set of indicators of quality of care in nursing homes, using resident level data from the MDS.  (See Zimmerman, et. al, for a more detailed discussion of the QI development and testing.)  Researchers at CHSRA also developed a report that showed the proportion of residents with the conditions reflected in the QI’s and compared a facility with a peer group of nursing homes.  A resident level report showed which residents had each QI condition.  Software developed at CHSRA has made it possible for every nursing home in the country to access and download its own reports, and every survey agency to access and download reports on all nursing homes in its state.  As a result of these initiatives, surveyors now have access to the QI reports for their use in survey activities, and nursing home staff have access to the information for use in their internal quality improvement initiatives.  Thus, the first two groups mentioned above now have access to valuable resident level information that can be used to enhance quality assurance and improvement efforts.

Consumer Use of the QI’s

The next logical step, of course, is to provide this type of information to consumers, to help them select nursing home care providers and to monitor the care in the facility.  In a companion article in this issue, Morris Kaplan has provided an interesting and useful discussion of the potential for using QI’s for finding a good nursing home.  He provides the reader with a good description of the QI’s, as well as some of the drawbacks of these types of measures.  One clarification of his discussion relates to his statement that the QI’s do not distinguish between conditions that developed prior to the admission to the nursing home and those developed during the resident’s stay in the facility.  In fact, the Provider QI Profile report excludes individuals who recently were admitted to the facility, which is an effective, albeit crude, method of removing from the analysis those cases in which conditions were likely to have been developed outside the nursing home.

Mr. Kaplan’s article  provides some useful tips on how the QI’s can be used in selecting a good nursing home.  My goal here is to expand on his discussion in two ways:

(1) to make sure that the QI’s are used appropriately for this purpose, and

(2) to emphasize the importance of the QI’s and other MDS information in monitoring the care provided, after the task of choosing a nursing home has been completed.

Using the QI’s Appropriately

The most important thing to remember about the QI’s is that their original and continuing purpose is to serve as a mechanism for identifying potential problems with care that should be reviewed and followed up in more detail.  Their purpose has not been to serve as a “measure” of quality, and they should not be used to make decisions about the quality of care without further inquiry or follow-up.  This is an important distinction, and one which consumers need to keep in mind.  Just as surveyors and internal nursing home staff can use the QI’s as a targeting mechanism to assist in assessing the quality of care, so can consumers and family members use them to make inquiries of nursing home staff members about the care provided at their facilities.

A related point is that more work needs to be done to “validate” the QI’s, in other words, to determine how well they predict quality of care.  The work that we have done to validate the QI’s has been limited to analyzing how well they can identify problems at the extreme—that is, how well do they accurately identify problems when the facility has a much higher proportion of residents with the QI condition relative to other facilities.  These validation results show that, when a facility “flags” (i.e., has a much higher proportion of residents with QI’s than its peers), the QI’s predict the presence of problems quite well.  But little work has been done to determine whether small or moderate differences below this extreme level are predictive of quality differences.

Now that nursing homes are submitting MDS data regularly to the state, there will be a wonderful opportunity to conduct more analysis of the QI’s in the future to help answer some of the questions raised above.  But until that time, it will be important to be cautious in how the QI’s are used, and not to overstep the boundaries of their use and value.

What does this mean for consumers?  

There are two important principles that consumers and family members should keep in mind in using the QI’s. 

·        First, they should focus on the areas of care where the QI reports identify a high proportion of residents with the QI condition. 

·        Second, consumers should be sure to follow up the review of the QI reports with additional inquiries and discussions with providers.

About the author:

David Zimmerman is the Director of the Center for Health Systems Research and Analysis at the University of Wisconsin-Madison. He has more than 15 years of experience in the evaluation of nursing home care and the development of outcome measures and information systems in long term care. He led the team of researchers that developed the MDS Quality Indicators is currently the Principal Investigator on two projects to use the QI’s in the survey process and in internal provider quality improvement initiatives.  He has been a long-time member and supporter of NCCNHR.