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Madison quality indicators keep nursing care on track

David R. Zimmerman

David R. Zimmerman (large image)

Back in the 1990s, as part of a project for the U.S. Health Care Financing Administration (HCFA), the University of Wisconsin-Madison Center for Health Systems Research and Analysis (CHSRA) began developing indicators that assess nursing home care quality.

Today, there are more than two million reasons — the number of residents living in the nation's 17,000-plus nursing homes — why the project was a success.

All of those nursing homes and others in about a dozen countries worldwide apply the quality indicators. The "CHSRA indicators" essentially are mechanisms that state and federal inspectors, accreditation agencies and nursing homes themselves use to target areas of nursing home care that need review for improvement.

The 24 indicators cover 12 areas of care: accidents, behavioral and emotional patterns, clinical management, cognitive patterns, elimination and incontinence, infection control, nutrition and eating, physical functioning, psychotropic drug use, quality of life, sensory functioning, and skin care. The data they generate are based on facilities' mandatory quarterly assessments of each resident, called the Minimum Data Set (MDS).

For example, under the "clinical management" quality indicator, an excessive number of residents who received nine or more different medications during the most recent assessment period would raise a red flag. "Just being on nine or more medications doesn't necessarily mean that you've got bad drug policy," explains David Zimmerman, CHSRA director and UW-Madison adjunct professor of industrial engineering. Instead, the indicator might mean that the nursing home should be aware that the chances are higher for such residents to experience adverse reactions, which if not identified and acted on quickly might require hospitalization. Similarly, the "skin care" indicator might point out that an unusually large number of residents have pressure (bed) sores; therefore, a nursing home might need to identify a more effective way of preventing pressure sores, as well as treating that condition when it occurs.

Nursing homes submit MDS information to their state and now can access their quality reports via software the CHSRA group developed. The software enables nursing homes not only to monitor their progress, but also compare reports with those of other facilities in their state, says Zimmerman.

When the project first began, CHSRA staff identified nearly 200 indicators based on nursing home data in five states. "We subjected them to external clinical review and reduced them to about 100 indicators," he says. "Then we conducted extensive analysis over a couple of years and reduced them to 30 indicators." To determine whether the indicators were valid measures of quality, CHSRA staff then sent clinical teams into nursing homes in four states to assess care and compare the results to what the indicators predicted. Later, to accommodate a new version of the MDS, the project team reduced the number of indicators to its current 24.

Now the Centers for Medicare and Medicaid Services (formerly HCFA) is using the indicators as the basis for a second-generation set of quality mechanisms that not only would apply to nursing homes, but also to other settings, such as post-acute care. Zimmerman is consulting for the project.

CHSRA staff also are working on an offshoot project of the original quality indicators endeavor. To start, the center formed a partnership with an association serving nonprofit nursing homes, both in Wisconsin and at the national level — a move that generated a whopping 700-plus nursing home participants at the project's peak. That number since has leveled off to about 450 — still much higher than the 100 facilities the group expected would take part, says Zimmerman.

Initially, CHSRA provided quality reports to those nursing homes that submitted their MDS data; soon those reports will be available online. "We also provide them with a manual of how to use the reports," he says. "And we've now supplemented that manual with specific protocols they can use to review individual care areas." The protocols detail investigative and follow-up guidelines for each quality indicator. In addition, the center publishes a newsletter for project participants and is developing a website through which nursing homes can submit their data electronically and search related health care resources. "The project actually resulted from our view that it's as important to teach people — practitioners, regulatory staff and consumers — how to use this information," says Zimmerman.

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2/18/2002