In support of the Centers for Medicare and Medicaid Services (CMS), Healthcare Management Solutions, LLC (HMS) is implementing changes across CMS’ State Performance Standards System (SPSS) to ensure that state agencies are effectively conducting survey and certification activities of healthcare facilities which in turn ensures patients are cared for appropriately within these facilities.
This project is the next phase of work HMS performed between 2018 and 2021, where we evaluated the SPSS, identified problems, made recommendations for improvements, and began implementation of those recommendations.
Introducing the SPIRIT Report
As we continue implementing recommended changes across SPSS, we also introduced a monthly report (known as the SPIRIT report), which is distributed to all states to update them on various indicators of state performance. The SPIRIT report is a mechanism that enables states to track their performance, identify possible areas of concern, and then use that information to improve in those areas.
For example, the SPIRIT report might show that state surveyors identified no citations on any of their compliance surveys. This would be something the state may want to investigate further, since surveys typically note at least a few issues at a healthcare facility. Identifying this pattern in the SPIRIT report alerts the state so it can assess what’s happening (i.e., Is there a gap? Is further investigation needed?). Likewise, if the state identifies an issue or a problem, it can use the SPIRIT report to monitor the effectiveness of the improvement plan it puts in place.
The SPIRIT report also helps state agencies identify high priority activities that are not being conducted. For example, if a very serious complaint is reported that might involve a patient’s death or potential harm to nursing home residents, the state must prioritize a visit to that facility very quickly, typically within two days. The SPIRIT report reveals to the state what proportion of its high-priority complaints are actually getting surveyed within that two-day time period. If the state’s surveyors are only getting out to, say, 60% of those high-priority complaints, the state agency can investigate the reasons for that performance.
Training States to Use Their Data
The SPIRIT report looks at a variety of different providers, including acute and continuing care data for ESRD facilities, hospitals, hospice facilities, home health agencies, and nursing homes. However, it’s crucial that people can properly review and analyze the report’s information to make informed decisions. HMS has conducted training sessions on the SPIRIT report for states and CMS locations, walking them through each of the measures and explaining what they mean and describing the parameters so states can interpret them properly. We employ examples such as the ones mentioned above throughout the training to demonstrate how to use the report.
HMS’ Expertise Helping CMS and States
HMS brings deep knowledge and understanding of survey and certification data, how to use that data to calculate measures, and what those measures mean. We understand the data system and data variables, so we’re well positioned to provide training and insight within the overall context of the survey and certification process.
HMS has been integral to the evaluation and improvement of the SPSS, providing new or expanded capabilities that include:
- Expanded capacity to conduct data analysis of survey and certification data (including ACTS data).
- Expanded experience conducting pilot testing.
- Expanded experience revising performance measures and developing new performance measures.
- Expanded experience in providing technical assistance and troubleshooting of piloting issues with CMS location staff.
- New capacity in rolling out a revised performance measurement system.
- New capacity to develop databases on the CMS SharePoint Site.
- Expanded experience developing composite measures from data.
- New capacity working in SAS Viya, CMS’ replacement data mining and analysis tool for QBIC.
Thanks to the breadth and expertise of the HMS team, which includes data scientists plus policy and program team members, we’re able to help CMS ensure that its SPSS measures state performance effectively. The work ultimately protects vulnerable populations by ensuring states are properly evaluating healthcare facilities in accordance with regulations.