State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Description of Quality Improvement Programs in Missouri


The Missouri Quality Improvement Program for Missouri (QIPMO) is an on-site clinical consultation program intended to assist nursing homes with their quality improvement programs. There are several distinctive features of the QIPMO program:

  • Nursing facility participation in the program is voluntary. Facilities self-select to have a QIPMO visit by contacting the QIPMO coordinator at the University of Missouri. In 2000 there were 459 QIPMO visits made to 212 nursing facilities. Through July 10, 345 site visits to 163 different facilities had been conducted. (There are about 600 nursing homes in Missouri, and about 45 percent of these have participated in the program).

  • The program operates separately from the state survey agency. QIPMO is a state-funded program, but the State's Long-Term Care Regulation department has virtually nothing to do with the day-to-day operation of the program, and provides only broad oversight of it (e.g., summary reports of QIPMO nurse activity). Missouri is the only state that operates its technical assistance program through a university.

  • QIPMO is entirely separate from the state survey and enforcement process. Unlike other states with technical assistance programs, QIPMO nurses are not surveyors and they have no training in the survey process. Instead, they are gerontological clinical nurse specialists. QIPMO visits are confidential (except in the rare cases where cases of immediate jeopardy or actual harm to residents are encountered). No details about QIPMO visits are reported to the survey agency (not even which facilities were visited). QIPMO nurses do not answer regulatory questions. They do not interpret regulations. Their focus is on best practices, evidence-based practice, and standards of care. This separation lets surveyors focus on regulation, while QIPMO focuses on quality of care.

  • QIPMO makes much greater use of the MDS quality indicators than do other states. The same researchers who developed QIPMO also developed the Missouri "Show-Me Quality Indicator Report," which helps facilities track trends in quality indicators derived from the MDS. A major focus of QIPMO is helping facilities to understand the "Show Me" reports and help them use the quality indicators to develop or refine their quality improvement program. Some QIPMO visits are focused on MDS coding issues, since these contribute to facility quality indicator scores.

  • The QIPMO program is research-based. The design of QIPMO was influenced by the results of a randomized clinical trial that was conducted in 1999. In this trial, facilities were assigned to one of three groups (facilities that received workshop and feedback reports only, facilities that also received clinical consultation, and a control group.) This research showed that on-going on-site clinical consultation is effective in influencing change in nursing care that affects resident outcomes. This research was the foundation for QIPMO and the "Show Me" reports.

  • The effectiveness of QIPMO has been studied in-depth. Dr. Rantz and her colleagues have studied the impact of QIPMO on CHRSA quality indicators in the state. Since the implementation of QIPMO, there have been improvements in 16 quality indicators and a decline in only six measures. In addition to analyzing median quality indicator scores, the research team analyzes trends for the 90th and 95thpercentile, so that the effectiveness of the program in improving outcomes for low-quality facilities can be understood.

The QIPMO program includes several integral components:

  • Computerization of State Specific Reports using MDS Data--the "Show-Me Quality Indicator Reports"
  • On-Site Clinical Consultation Visits
  • Standardization of MDS Education
  • Monthly Support groups for MDS coordinators
  • Surveyor Training, Provider Meeting Participation and other Educational Programming on clinical topics of importance to resident care

The state also has a Best Practices program administered through the Central Missouri State University.

"Show-Me" Quality Indicator Reports

Electronic longitudinal "Show-Me" Quality Indicator Reports are compiled each quarter and available on-line via the statewide computer network for all nursing facilities in the state. These reports show how each facility is performing over the past five quarters for each CHSRA quality indicator in comparison to statewide tenth percentile thresholds. The reports were developed by Marilyn Rantz and colleagues and are used by the QIPMO nurses to structure and guide the on-site technical assistance visit.

The "Show-Me" Quality Indicator Report consists of the CHSRA quality indicator trend graphs and summary tables, displayed one indicator per page, along with a resident roster listing each resident with the quality indicator(s) that they trigger. The summary table contains by quarter, the facility's QI score, number of residents with the QI, number of residents included in the calculation, number of residents not in the calculation, the applicable MDS items and the statewide summary. Statewide summary includes the tenth percentile score and the facility's ranking in Missouri. Each page also includes a definition of the indicator and explanation of the upper and lower thresholds. Appendix Bcontains a sample "Show Me" report.

On-Site Clinical Consultation Visits

Beginning in mid-2000, specially trained QIPMO nurses have conducted technical assistance visits at nursing facilities, residential and intermediate care facilities. These visits are voluntary, consultative, confidential and intended to assist nursing homes with their quality improvement programs. The technical assistance component to QIPMO was pilot tested with 113 facilities in 1999. Results of the pilot indicated that on-going on-site clinical consultation by an advanced practice nurse was effective in improving care and outcomes for residents in nursing facilities.

Each visit is facility-specific and begins with a review of the facility's "Show-Me" Quality Indicator Reports. After an understanding of the QI definitions and reports is achieved, QIPMO visits often result in the identification of specific clinical indicators that may need further review. Facility staff are guided through the process to determine whether the QI result is an accurate representation of their residents, beginning with a check of the accuracy of the MDS item coding and progressing to a review of facility care processes in terms of their ability to meet accepted clinical standards. Using the resident roster generated as part of the "Show-Me" reports, QIPMO nurses use actual facility residents to focus discussion on MDS accuracy and resident-specific care processes.

There is no charge associated with the visit. In the course of a QIPMO visit, depending on the needs of the facility, the clinical team may conduct group discussions with members of the nursing care team including nursing assistants, observe care processes, review medical records and provide in-service programs on a variety of MDS-and clinical care-related topics.

Standardization of MDS Education

Recognizing that accurate QI reports would provide the foundation for quality improvement efforts and that accurate MDS assessment data was critical to valid QI reports, University of Missouri faculty partnered with the Missouri Division of Aging to convene a group of industry representatives to guide the on-going state needs for staff education on the MDS. The group included representatives from the Missouri Health Care Association, the Missouri Hospital Association, the Missouri Association for Homes and Services for the Aging and the Missouri League of Nursing Home Administrators. Their goal was to provide consistent and accurate information on the MDS and use the MDS data for quality improvement. The group began meeting in March 1997 and continues to meet on a quarterly basis. In the first year, they developed standardized educational materials on the MDS which are currently required to be used by any individual or organization providing MDS education in the state.

Training materials consist of an "Item-by-Item Guide to the MDS" and a "Case Study: Mrs. M." The Item-By-Item Guide is a reference for correct coding and definitions of MDS items. The Case Study is used for teaching the Resident Assessment Protocols and care planning. They are intended for use with the interdisciplinary team and not just for nursing staff. Workshops are provided several times a year at varied locations throughout the state.

Monthly Support Groups for MDS Coordinators

As they conducted their technical assistance visits, QIPMO nurses became increasingly aware of the high turnover of MDS Coordinators. Believing that the turnover was related to a lack of resources, a lack of support, lack of understanding of their role by administrative staff and co-workers and feelings of stress in their positions, the QIPMO nurses initiated monthly support group meetings in May 2000 in the St. Louis area. Since then, monthly meetings have expanded to the seven geographic regions of the state covered by the seven QIPMO nurses. The support group goals include: (1) Improve MDS coding accuracy, (2) Enhance job satisfaction for MDS Coordinators, and (3) Increase overall staff retention rates.

Meetings are facilitated by QIPMO nurses and are held at volunteer facilities in each region. There is no charge for the meeting, with expenses for mailings covered by the host facility. QIPMO nurses schedule the meetings, select topics or speakers and serve as resources. Meeting formats vary based on the interests and concerns of the group, and problem solving occurs collaboratively. The state regulatory agency, particularly the state MDS coordinator, has been supportive of the group and has visited each region to give the participants the opportunity to ask questions. State technical support staff have also attended meetings, as have regional surveyors.

Surveyor Training, Provider Meeting Participation and other Educational Programming

QIPMO nurses participate in educational programs for state surveyors, providing both annual statewide training and regional training that focuses on clinical topics and the MDS/RAI process. The goal is to provide education for surveyors that is consistent with the information presented to nursing home staff as part of QIPMO. QIPMO nurses also participate in statewide provider meetings conducted and sponsored by the Division of Aging. In 2000 and 2001, provider meetings were held in various cities throughout the state. There was a one-day session sponsored by the Department of Health and Senior Services (DHSS) in which information about the regulatory process was discussed. At the meeting, which was attended by several hundred providers, the QIPMO nurses spoke about their program, which is strongly endorsed by DHSS staff.

Best Practices Program

The Best Practices Program is administered by Central Missouri State University and is unaffiliated with the state survey agency, although it is supported by state funds. A statewide committee, which includes seven representatives from each of the two provider associations and several staff from the state Ombudsman's office, reviews applications from facilities. The committee determines the topics and solicits applications. Thirty facility practices were nominated in 2001. These nominated practices are published and disseminated by the university. Until last year (when there was no conference), award winners were recognized at the Governor's Conference on Aging.

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