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Purpose
One of the original intended uses of the MDS was monitoring of nursing home quality of care. The first formal articulation of nursing home Quality Indicators (QIs) to receive significant recognition was proposed by Dr. David Zimmerman, an interRAI fellow, and colleagues of the Centers for Health Systems Research and Analysis at the University of Wisconsin (CHSRA) and shortly thereafter by LTCQ, Inc., among other authors.
Nursing home outcomes-based QIs, as well as home care QIs and specialty mental health care QIs, are defined in terms of clinical characteristics collected by the MDS. QIs use MDS elements to establish a measure that can be translated into a statistical summary. While QIs are defined in terms of individual characteristics, they only take on meaning when expressed as averages at the facility or agency level. QIs are defined at the individual level as binary variables, and aggregated to the facility or agency level to produce summary measures reflecting presumed quality of care. In their raw form, QIs are expressed as fractions. Therefore, QIs can be described in terms of numerators and denominators. Each QI has an explicit definition and inclusion/exclusion criteria.
An obvious advantage of MDS based quality indicators are that they are derived directly from the assessment instrument, thus facilitating their calculation without the need for additional data collection. Quality indicators are currently used for many different purposes e.g., by care providers for improving care, by governments to monitor care, and for public reporting.
CHSRA
These quality indicators are regarded as pointers that indicate potential problem areas that need further review and investigation. They are the starting point for a process of evaluating the quality of care. Currently the CHSRA quality indicators include a fixed set of 24 QIs organized into 11 care domains. For more information on these QI definitions go to CHSRA.
LTCQ
For more information on these quality indicators go to LTCQ.
MEGA QI Project
Dr. John N. Morris, another interRAI Fellow, helped lead a five-year effort to develop and validate quality indicators for post-acute and long-term care institutional settings, funded by the United States Centers for Medicare and Medicaid Services (CMS). In this effort, researchers first identified QIs that were already widely used. They next created new indicators to "fill in the gaps." A major field study was completed that both evaluated the reliability of the MDS data on which these indicators are based and assessed the validity of the indicators themselves.
Three major reports arose from this contract:
In the first report, the array of existing and new indicators was identified that would be appropriate to long stay and rehabilitative nursing-home care.
Report
In the second, the results of the national field validation of these indicators were reported.
Report
Appendicies Table of Contents
Appendix A
Appendix B
Appendix C
Appendix D
Appendix E
Appendix F
Appendix G
Appendix H
Appendix I
Appendix J
Appendix K
Appendix L
Appendix M
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In the third report, which was completed in December 2002, new strategies for risk adjustment of these indicators were suggested.
Report
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Appendix 7
Appendix 8
Appendix 9
Appendix 10
Appendix 11
Appendix 12
Appendix 13
These reports and supporting documentation are distributed on the CMS Nursing Home Quality Initiative website.
The US government has implemented a number of the Mega QI indicators to give consumers information about how well nursing homes are caring for their residents' physical and clinical needs. These quality measures show ways in which nursing homes are different from one another. The measures are not benchmarks, thresholds, guidelines, or standards of care, and are not appropriate for use in a litigation action. The US government currently uses six quality measures for long-term care residents, and three based on short stay residents: For more information on the US Nursing Home Quality Initiative, go to the Nursing Home Compare website.
Home Care
interRAI has also created its first version of Home Care Quality Indicators, or HCQIs. The 22 HCQIs cover 9 domains (nutrition, medication, incontinence, ulcers, physical function, cognitive function, pain, safety/environment, other) and were derived using data from Canada, US, and Italy. Their use is now being tested in multiple countries. InterRAI Home Care Quality Indicators (HCQIs) Definitions25 draft Quality Indicators for in-patient mental health are currently being evaluated.
References
Morris J, Murphy K, Mor V, Berg K, Moore T. Validation of Long Term and Post Acute Care Quality Indicators. Final Draft Report, August 2, 2002. CMS Contract 500-95-0062.
Mor V, Morris J, Lipsitz L, Fogel B. (1998). Benchmarking Nursing Home Quality: The Q-Metrics System. Canadian Journal of Quality in Health Care. 14(2): 12-17.
Phillips C, Zimmerman D, Bernabei R, Jònsson D. (1997) Using the Resident Assessment Instrument For Quality Enhancement In Nursing Homes. Age and Aging. 26 (Supplement 2):77-82.
Zimmerman, DR, Karon, S L, Arling G, Clark BR, Collins T, Ross R, Sainfort F. (1995). Development and Testing of Nursing Home Quality Indicators. Health Care Financing Review. 16(4):107-127.
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