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GAO Calls for Better CMS Monitoring of Quality Indicator Survey Implementation

by Published On: Mar 09, 2012

CMS Should Improve Efforts to Monitor Implementation of the Quality Indicator Survey is a report released by the Government Accountability Office (GAO) on March 2 recommending that the Centers for Medicare and Medicaid Services (CMS) develop a more systematic approach, including performance goals and measures, to routinely monitor the extent to which the Quality Indicator Survey (QIS) is meeting CMS’ objectives to improve the efficiency, accuracy, and consistency of the long-term care survey process. 

In addition to the need for performance goals and measures, the report recommends that CMS develop and implement a methodology to track state survey agencies’ progress with implementation activities; and for obtaining, compiling, and sharing information from state survey agencies about their implementation experiences. 

Background 

  • CMS developed the Quality Indicator Survey (QIS) to improve the efficiency, accuracy, and consistency of the survey process by improving surveyors’ identification and documentation of quality concerns; focusing resources on facilities, and on areas within facilities with the greatest quality concerns.
  • CMS commissioned three studies to evaluate the Quality Indicator Survey (QIS) process, but it does not routinely monitor the extent to which the objectives established for the QIS are being met.
  • The first two studies, completed in 2006 and 2007, respectively, by Abt Associates were to determine whether the QIS process could be used “…under real-world conditions…” and whether the QIS meeting several of CMS’ objectives for the process.
  • A third study 2011, identified aspects of the QIS that could affect how consistently surveyors identify quality problems and potential approaches for addressing these issues, e.g., during resident interviews, surveyors did not consistently probe for further information when provided with incomplete responses.
  • For this Report, GAO examined the extent to which CMS (1) evaluates whether progress is being made in meeting the objectives of the QIS; and (2) monitors and facilitates states’ implementation.
    • GAO reviewed CMS’ plan for evaluation and improvement of the QIS; CMS-commissioned studies of the QIS, policies, and guidance; interviewed officials from CMS’s Central and all 10 Regional Offices and officials from a “judgmental sample”’ of nine state survey agencies (SAs) [AZ, CO. CT, FL, MD, MN, NY, OH, WV].

What GAO Found

  • CMS has not established the means—e.g., performance goals and measures—to routinely monitor the extent to which the QIS is meeting its objectives to improve the survey process.
  • While CMS has taken some steps to monitor and facilitate states’ implementation of the QIS-based routine survey,  these efforts are not systematic and Information on States’ implementation progress is incomplete.
  • CMS established three milestones to guide states’ implementation of the QIS: 

    1. Start dates by which each state is to begin training state surveyors. 
    2. Completion of training for all surveyors within three years of the training start date.
    3. Use of the QIS for all routine surveys after all state surveyors have completed training. However, CMS relies primarily on quarterly teleconferences with SAs for information on the extent to which each state has completed surveyor training.
  • States may not always participate, and those that do may not provide complete information on their progress. For example, CMS was unable to provide GAO with information on completion dates for all state surveyors in states that completed training.
  • To facilitate QIS implementation, CMS has issued with periodic guidance and/or clarifications and updates; conducted presentations; and has provided opportunities to share  implementation experiences. However, the Agency has no systematic method for obtaining, compiling and sharing information on state experiences.

GAO Recommends 3 Actions 

As CMS continues to implement the QIS, the Administrator of CMS should:

  • Develop a means—such as performance goals and measures—to routinely monitor the extent to which CMS is making progress in meeting the objectives established for the QIS.
  • Develop and implement a systematic methodology to track state survey agencies’ progress with implementation activities.
  • Develop and implement a systematic method for obtaining, compiling, and sharing information from state survey agencies about their implementation experiences.”

HHS/CMS Response 

  • HHS reviewed a draft of this report on behalf of CMS, concurred with all three recommendations and advised it “…would work to implement them expeditiously.” HHS said that CMS will:  
    • Establish new or modify existing measures or processes to more effectively monitor CMS's progress toward meeting QIS goals and objectives;
    • Formalize the data collection method used to track states' progress with QIS implementation activities; and
    • Enhance existing and add new methods of sharing information on the QIS with states.
  • HHS also notes "CMS has reassessed the timetable for QIS expansion to additional states due to budgetary concerns, and the QIS will not be introduced to additional states in fiscal year 2012 as planned.”  “…CMS will instead focus efforts on more effectively implementing the QIS in those states where training of state surveyors has begun or has been completed, addressing barriers to QIS implementation, and completing the remaining components of the QIS.”
  • CMS expects the QIS to be implemented in all 50 States, DC, Puerto Rico and the US Virgin Islands by 2018.  

 

 



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