Glossary of Terms

The materials comprising the Quality Indicator Survey manuals and forms contain many new terms and acronyms. The glossary below was extracted from the back of the QIS Surveyor Training Manual — you can also download the QIS Glossary of Terms.

If you encounter any QIS-related terms that you don't know and that are not defined in the glossary, please contact us at info@nursinghomequality.com for help.

Admission Sample

The Admission Sample consists of 30 residents randomly selected by the Quality Indicator Survey (QIS) Data Collection Tool (DCT) to undergo clinical record review by the survey team during Stage 1. Residents are eligible for inclusion in the Admission Sample if they have had completion of an admission MDS (Minimum Data Set) within the 180 day period before the beginning date of the survey.

Admission Sample Report

The Admission Sample report lists the residents selected by the QIS DCT for inclusion in the Admission Sample (during which clinical record review is completed for 30 residents).

• One copy of the Admission Sample report is provided to the facility for use when gathering discharged residents' clinical records for review by the survey team (clinical records for Admission Sample residents who are currently residing in the facility are reviewed on the unit). Before providing the report to the facility, the survey team will use the facility's resident census to reconcile residency/discharge status for residents on the Admission Sample report, blacking out current residents' information.
• The second copy of the report is used by the survey team when marking record reviews as being completed.

Aspen (Automated Survey Processing Environment) Central Office (ACO)

ASPEN (Automated Survey Processing Environment) Central Office is a Windows®-based program that enables State Agencies (SAs) to implement information-based administration of the health care facilities under their supervision. ACO stores data about certified facilities regulated by the Centers for Medicare & Medicaid Services (CMS) and the regulations pertinent to those facilities. ACO includes full survey operations support, which enables agencies to centralize survey event planning, and team assignment in addition to providing access to MDS resident and assessment information (historical and current) and regulatory and interpretive guidelines. ACO provides survey performance reporting and integration with Quality Measure/Indicator (QM/QI) statistics, which facilitates inclusion of survey findings in the State Standard System.

Aspen Survey Explorer (ASE)

ASPEN (Automated Survey Processing Environment) Survey Explorer is a Windows®-based program that enables State Agencies to implement information-based administration of the health care facilities under their supervision. ASE stores data about certified facilities regulated by the Centers for Medicare & Medicaid Services (CMS) and the regulations pertinent to those facilities. ASE provides access to MDS resident and assessment information (historical and current), regulatory and interpretive guidelines, and the Quality Indicator Survey Data Collection Tool (QIS DCT) via the Citation Manager.

Care Area

A Care Area refers to a critical component of nursing home care that, in the QIS process, is defined by one or more related resident-centered outcome and process indicators called Quality of Care Indicators (QCIs). If Stage 1 information gathering identifies residents whose QCI data exceeded rate thresholds for Care Areas, or "triggers" Care Areas, Stage 2 will involve in-depth investigation of the residents using Critical Element Pathway(s) (CEs) to systematically review information and document concerns.

Census Sample

The Census Sample consists of 40 residents currently residing in the survey facility who are randomly selected by the QIS DCT for information gathering by surveyors through interview, observation, and record review during Stage 1 of the QIS process.

Critical Element Pathway (Investigative Protocol)

A Critical Element (CE) Pathway corresponds to an associated Care Area identified in Stage 1 and provides information to guide Stage 2 QIS process investigation. A CE Pathway assists surveyors to determine whether a facility undergoing survey meets the associated regulatory requirements by incorporating each step of the resident care process reflected in the regulations:

• Assessment,
• Care planning,
• Implementation of care that meets professional standards, and
• Monitoring of care.

A General Critical Element Pathway is available for a resident having a care issue not addressed in one of the specific CE Pathways. The Critical Element Summary Form documents investigation results for use during team discussion, decision-making, or documentation in the QCI DCT.

Facility-level Tasks

Facility-level tasks are not specific to any one resident and are completed by the survey team throughout Stage 1 and/or Stage 2 of the QIS process. The six facility-level tasks completed on every survey include: Resident Council President/Representative Interview, Dining Observation, Kitchen/Food Service Observation, Infection Control, Demand Billing, and Quality Assessment and Assurance Review. The survey team completes task specific worksheets from which information is entered in QIS DCT during Stage 2. Five additional facility-level tasks are assigned and completed during Stage 2 only if triggered during Stage 1. These triggered tasks are Environmental Observation, Resident Funds, Admission, Transfer, and Discharge Review, Sufficient Staff, and Abuse Prohibition Review.

Family Interview

A family interview is conducted during Stage 1 of the QIS process for each of three families (or representatives) of Census Sample residents. The Family Interview applies in cases in which the resident is unable to be interviewed (e.g., due to cognitive difficulties).

MDS Sample

The MDS Sample consists of a facility's residents who have had completion of an MDS Assessment (except discharge or re-entry assessments) within the 180 days before the survey.

Residents who have only an Admission, Discharge, or Re-entry MDS Assessment within the 180 days before the survey are excluded. The MDS Sample is drawn offsite in the QIS DCT, which then uses the MDS Sample data for QCI calculations that will identify residents to be further investigated during Stage 2 of the QIS process.

New Admission Information Report

The New Admission Information Report is generated by the QIS DCT, and is provided to the facility to record all residents who have been admitted within the 30 days before the survey date. The survey team uses the information to update the Admission Sample and the Census Sample in the QIS DCT.

Primary Laptop

The primary laptop refers to the survey laptop used by the team coordinator and designated to process the MDS QCIs, draw the Stage 1 Sample, calculate QCIs based on merged Stage 1 data from all survey laptops, create the Stage 2 sample, report and assign Stage 2 Critical Elements and import the potential citations into ASE.

Quality Indicator Survey (QIS)

The Quality Indicator Survey (QIS) process is a standardized, computer-assisted, systematic two-stage process, using large random samples, and a threshold data base to compare the facility under survey to all others in a large set of subject areas (QCIs).

Quality Indicator Survey Data Collection Tool (QIS DCT)

The Quality Indicator Survey Data Collection Tool (QIS DCT) is the software used to facilitate data collection during the QIS process. The QIS DCT processes MDS data, draws the Stage 1 and Stage 2 samples, is used to input survey information (document relevant findings) for Stage I and Stage 2 data, merges Stage 1 and Stage 2 data collected at all survey laptops, calculates QCIs, and provides review of potential citations and assignment of each citation's scope and severity. The QIS DCT is accessed through the Citation Manager of ASPEN Survey Explorer.

Quality of Care Indicators (QCI)

Quality of Care Indicators (QCIs) are resident-centered outcome and process indicators constructed from calculations of downloaded MDS Data and data collected onsite during a survey (i.e., observations, interviews, and clinical records review). Once compared with national and/or state norms, QCIs focus the Stage 2 review of Stage 1 findings.

Relevant Findings

Relevant findings are surveyors' documentation of additional findings related to observed problems, areas of concern, and sources of findings related to a prescribed Care Area review or facility-level review. Relevant findings can be entered as narrative text in the QIS DCT and subsequently printed as a report for review, to facilitate team discussions of potential problems, and to assist in Stage 2 information analysis, decision-making, or deficiency writing as appropriate. Relevant findings not included in the prescribed review can be used to determine whether to surveyor initiate a particular Care Area for in-depth review in Stage 2.

Resident Council President/Representative Interview

The Resident Council President/Representative Interview (which replaces the Group Interview) is a facility-level task that focuses on resident rights, facility rules, and facility responsiveness to council concerns. If there is no resident council leader or officer, the interview questions can be asked of a resident who is active in the council as indicated by the facility. As part of the interview, surveyors can review resident council minutes to become familiar with issues that have been discussed before the interview.

Secondary Laptop

A secondary laptop is the survey laptop used by a team member (other than the team coordinator) to enter gathered information for assigned sample residents and facility-level tasks. When information gathering is complete at the end of Stage 1 and Stage 2, the data is exported to disk from the secondary laptops and then imported (or merged) on the primary laptop.

Stage 1

Stage 1 is the portion of the survey process in which Census Sample and Admission Sample residents are randomly selected and assigned in the QIS DCT software; subsequently the survey team, using QIS process worksheets, conducts resident, family, and staff interviews, and makes and records observations. Stage 1 findings are the basis of QCI calculations, which focus the Stage 2 in-depth review of Care Areas that exceeded QCI thresholds.

Stage 2

Stage 2 is the portion of the survey process in which an in-depth directed review is conducted of residents within Care Areas that exceeded thresholds identified during the Stage 1 process. Surveyor-initiated Care Areas are investigated, and facility-level tasks are completed during Stage 2. Compliance decisions are made at the completion of Stage 2.

Surveyor-initiated Sample

The surveyor-initiated sample consists of residents specifically chosen by surveyors (not randomly selected by the QIS DCT) to be further evaluated during the Stage 2 Care Area in- depth review. This sample can be based on resident- or facility-specific information obtained from ombudsman information, off-site complaints, surveyor observation, or interviews.

Threshold

The term threshold refers to the prevalence rate established to govern the decision whether to conduct a Stage 2 investigation in a particular Care Area. The prevalence rate consists of a defined numerator and denominator for each QCI. Thresholds established for each QCI are based on distribution data from numerous facilities or concerns-based absolute standards.

Trigger

The term trigger refers to the initiation of Stage 2 investigation of a Care Area whose threshold has been exceeded based on Stage 1 findings from observation, interviews, or record reviews, and MDS data for specific residents.