CHSRA indicators deemed a success

The Center for Health Systems Research and Analysis (CHSRA) indicators are being called a success after nearly a decade of use, and the developers say the development process should be a model for the creation of other quality indicators. The CHSRA indicators were developed in the 1990s as part of a project for the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services) by the University of Wisconsin-Madison (UW-Madison) to assess nursing home care quality.

The university’s assessment calls the indicators a success in helping measure quality for more than two million residents living in the nation’s 17,000-plus nursing homes. All of those nursing homes and others in about a dozen countries worldwide apply the quality indicators. The CHSRA indicators essentially are mechanisms that state and federal inspectors, accreditation agencies, and nursing homes themselves use to target areas of nursing home care that need review for improvement, says David Zimmerman, CHSRA director and UW-Madison adjunct professor of industrial engineering.

The 24 indicators cover 12 areas of care: accidents, behavioral and emotional patterns, clinical management, cognitive patterns, elimination and incontinence, infection control, nutrition and eating, physical functioning, psychotropic drug use, quality of life, sensory functioning, and skin care. The data they generate are based on facilities’ mandatory quarterly assessments of each resident, called the Minimum Data Set (MDS). For example, under the "clinical management" quality indicator, an excessive number of residents who received nine or more different medications during the most recent assessment period would raise a red flag.

"Just being on nine or more medications doesn’t necessarily mean that you’ve got a bad drug policy," Zimmerman says. Instead, the indicator might mean that the nursing home should be aware that the chances are higher for such residents to experience adverse reactions, which, if not identified and acted on quickly, might require hospitalization.

When the project first began, CHSRA staff identified nearly 200 indicators based on nursing home data in five states. To determine whether the indicators were valid measures of quality, CHSRA staff then sent clinical teams into nursing homes in four states to assess care and compare the results to what the indicators predicted. Later, to accommodate a new version of the MDS, the project team reduced the number of indicators to its current 24.

Now the Centers for Medicare & Medicaid Services is using the indicators as the basis for a second-generation set of quality mechanisms that would apply not only to nursing homes, but also to other settings, such as post-acute care. Zimmerman is consulting for the project.