Quality Indicators: Original CHSRA QIs

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History of CHSRA Quality Indicator Development

Researchers at the Center for Health Systems Research and Analysis (CHSRA), University of Wisconsin-Madison developed and tested a set of indicators of quality of care in nursing homes and a quality monitoring system for using the indicators for internal and external quality review and improvement. The development of the quality indicators (QIs) and quality monitoring system (QMS) resulted from two related developments in the field of nursing home quality assurance. The first was the growing interest among health care professionals, consumers, policy makers, and advocates about issues related to the quality of care and quality of life of nursing home residents. The second was the Multistate Nursing Home Case Mix and Quality (NHCMQ) Demonstration funded by the Centers for Medicare & Medicaid Services (CMS).

The QIs and QMS originally were derived from items on the Minimum Data Set Plus (MDS+). The MDS+ was an enhanced version of the MDS, developed for use within the NHCMQ Demonstration. Comparable QIs were subsequently developed to make use of the MDS Version 2.0.

The QIs were formulated and developed through a systematic process involving extensive interdisciplinary clinical input, empirical analyses, and field testing. Clinical and research staff at the University of Wisconsin-Madison developed an initial draft of a set of indicators and potential associated risk factors based on an extensive review of relevant clinical research literature and the care-planning guidelines from the Resident Assessment Protocols (RAPs). Several national clinical panels representing the major disciplines involved in the provision of nursing home care reviewed the initial draft. These disciplines included nursing, medicine, pharmacy, medical records, social work, dietetics, physical therapy, occupational therapy, and speech and language therapy, as well as resident advocates and administrators. The clinical panels provided a rigorous critique and assisted in refining or deleting proposed QIs and defining new QIs. The clinical review culminated in the panels being convened in July, 1991 to provide an assessment of the QIs within and across disciplines. This important step was followed with in-depth review by a research advisory panel convened to provide consultation in areas of analytic concern. The panel members continued to provide consultation throughout the project. The result of the clinical panel meetings was a set of 175 QIs.

These 175 QIs served as the basis for empirical analyses. QI development was guided by several criteria including clinical validity, feasibility or usefulness of the information, and empirical analyses. Extensive analyses were performed to further reduce the set of QIs to a comprehensive set of 30 QIs covering the 12 domains which was reduced to a fixed set of 24 QIs organized into the 11 care domains listed below (see QI Descriptions.) The QIs and QMS were subjected to validation testing, and began being used by all state survey agencies and by a number of nursing homes (PIP) for quality assurance and improvement.

1. Accidents
2. Behavioral & Emotional Patterns
3. Clinical Management
4. Cognitive Functioning
5. Elimination & Incontinence
6. Infection Control
7. Nutrition & Eating
8. Physical Functioning
9. Psychotropic Drug Use
10. Quality of Life
11. Skin Care