In their external assessment of quality care, the QANs use protocols that incorporate the quality indicators developed by the Center for Health Systems Research and Analysis (CHRSA). Aggregated analyses of facility quality indicators are used in conjunction with other measures to identify facilities that may have more serious or particular types of care problems, based on comparison with their peers or through trend analysis. This is the first stage in a two-step process of assessing the quality of care. The second step, which the QANs perform as part of their facility visits, is to investigate further to determine whether the problem identifies by analysis of the data actually exists.
In general, the expectation is that a QAN visit will involve completing 1-2 protocols for approximately 5-8 residents. The state developed written protocols in selected areas in the mid 1990s, with final revisions in 1998. Each protocol includes a set of questions to be answered about care of a particular resident in a particular domain (e.g., skin integrity) with a place on which to mark the answer. For example, the skin integrity protocol asks among other things "[Was] skin impairment accurately assessed?" and "[Was] skin assessment comprehensive?" The protocols are closely tied to issues that are the focus of the survey even to the point of including reference to applicable F tags.