Quality Indicators: Original CHSRA QIs

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Quality Indicator Characteristics

The quality indicators (QIs) are markers that indicate either the presence or absence of potentially poor care practices or outcomes. QIs represent the first known systematic attempt to longitudinally record the clinical and psycho-social profile of nursing home residents in a standardized, relatively inexpensive, and regular manner by requiring the expertise of only in-house staff.

The QIs can be best described by addressing their characteristics along the following dimensions:

Resident/Facility Level QIs
Prevalence/Incidence
Process/Outcome

Resident/Facility Level QIs

At the resident level, QIs are defined either as the presence or absence of a condition. The resident level QIs can be aggregated across all residents in a facility to define facility level quality indicators. Facility level QIs can be used to compare any given facility with others or with nursing home population norms at the state or multistate level. An example of a resident level QI is the Prevalence of Falls defined as residents who have had a fall within the past 30 days as documented on the most recent assessment (i.e., are in the numerator). The denominator for the facility includes all facility residents on the most recent assessment. As is true for all QIs, the facility proportion is equal to the numerator divided by the denominator.

Prevalence/Incidence

QIs that are defined as the presence or absence of a condition at a single point in time is called a "prevalence QI", whereas a QI capturing the development of a condition over time (on two consecutive assessments for example) is called an "incidence QI". It should be noted that while prevalence in QIs relate to a single point in time for each resident, at the facility level they represent the prevalence of conditions over a three-month period, since the most recent assessment across the population of residents can occur over a quarter.

Process/Outcome

QIs cover both process and outcome measures of quality. Process indicators represent the content, actions and procedures invoked by the provider in response to the assessed condition of the resident. Process quality includes those activities that go on within and between health professionals and residents. Outcome measures represent the results of the applied processes. In the case of long term care it maybe most relevant to think in terms of a change in or continuation of health status. Outcome quality then should be represented by both prevalence and incidence indicators.

The distinction between a process and outcome QI is not always straightforward. In some cases the QI is a combination of an outcome and a process, in that it reflects both of them. An example is the prevalence of symptoms of depression (outcome) with no treatment (process) indicated. In other cases the QI can be considered either an outcome or a process measure, depending on the particular situation and one's philosophical orientation. An example is the QI Prevalence of Little or No Activity. This QI can be thought of as reflecting the status (outcome) of the resident (i.e., the resident is not able to or chooses not to engage in activities), or as a process of care (i.e., the facility staff elects not to provide or arrange for the activities). It may require subsequent investigation to determine whether, for a particular resident, the QI is more reflective a process or an outcome of care.

The QIs were designed to cover both process and outcome of care and to include both prevalence and incidence indicators.