Quality Indicators


Nursing home outcome-based QIs, as well as home care QIs and specialty mental health care QIs, are defined in terms of clinical characteristics collected by specific interRAI assessment systems. QIs use data elements to establish a measure that can be translated into a statistical summary. Each QI has an explicit definition and inclusion/exclusion criteria. While QIs are defined in terms of individual characteristics, they only take on meaning when expressed as averages at the facility or agency level. These summary measures reflect presumed quality of care.  Quality indicators are regarded as pointers that indicate potential problem areas that need further review and investigation.  Quality indicators are currently used for many different purposes, for example, by care providers for improving care, by governments to monitor care, and for public reporting.

An obvious advantage of interRAI quality indicators is that they are derived directly from the assessment instrument, thus facilitating their calculation without the need for additional data collection. Brief descriptions of QIs developed for specific assessment systems follow.

Home Care

The initial generation of Home Care Quality Indicators, or HCQIs, includes twenty-two HCQIs covering nine domains (nutrition, medication, incontinence, ulcers, physical function, cognitive function, pain, safety/environment, other).  They were derived using data from Canada, U.S., and Italy. Their use is now being tested in multiple countries.

Institutional Care

One of the original intended uses of the MDS was monitoring of nursing home quality of care. The first formal articulation of nursing home Quality Indicators (QIs) to receive significant recognition was proposed by Dr. David Zimmerman and colleagues of the Centers for Health Systems Research and Analysis at the University of Wisconsin (CHSRA).

Dr. John Morris, an interRAI Fellow, helped lead a five-year effort to develop and validate quality indicators for post-acute and long-term care institutional settings, funded by the U. S. Centers for Medicare and Medicaid Services (CMS). In this “Mega QI” effort, researchers first identified QIs that were already widely used. They next created new indicators to "fill in the gaps." A major field study was completed that both evaluated the reliability of the MDS data on which these indicators are based and assessed the validity of the indicators themselves. PAC Data  ADL Data

The U.S. government has implemented a number of the Mega QI indicators to give consumers information about how well nursing homes are caring for their residents' physical and clinical needs. These quality measures show ways in which nursing homes are different from one another.  The U.S . government currently uses six quality measures for long-stay residents and three based on short-stay residents.

Mental Health

The MHQIs reflect, primarily, the clinical outcomes and safety of mental health services. Indicators of clinical outcome are valuable for informing quality but often rare due to the difficulty collecting consistent information across health systems. With a consistent implementation of interRAI mental health tools across jurisdictions, the MHQIs can reflect patterns of change in a number of clinical domains as well as the prevalence of adverse clinical events. The domains include mental health symptoms, behaviours, cognitive performance, daily functioning, physical pain, interpersonal conflict, and restraint use. A total of 27 indicators are defined within these domains measuring the prevalence of adverse events at given points in time (5 indicators) as well as patterns of change based on improvement, incidence, or failure to improve in clinical domains (22 indicators).

The MHQIs are able to be applied to comparative performance and quality measurement initiatives as a strategy for case-mix adjustment is included for each MHQI. Traditionally, comparing outcome quality indicators between organizations is difficult because organizations often treat unique clinical populations, or case mixes. It is very important to adjust for these unique differences in order to make fair comparisons using the MHQIs. Therefore, extensive statistical modeling has been carried out to identify specific clinical characteristics that are to be adjusted for comparing each MHQI across organizations.

The MHQIs have applications for quality improvement, accountability, and public awareness.  Using the MHQIs, quality improvement opportunities within and between organizations, health regions, and health systems can be identified through the evaluation of contextual factors related to variations in the MHQIs. In terms of accountability, the MHQIs reinforce safety and recovery by reinforcing the minimization of restraints, reductions in behaviours, and improvements in how persons with mental illness feel and function. By focusing on improvement, the utility of the MHQIs extends beyond accountability by providing evidence to help demonstrate that mental health services can make a difference in improving the lives of those with mental health conditions.   


Hirdes J, Fries, BE, et al. 2004. Home Care Quality Indicators Based on the MDS-HC. Gerontologist 44(5): 665–79.

Mor V, Morris J, Lipsitz L, Fogel B. 1998. Benchmarking Nursing Home Quality: The Q-Metrics System. Canadian Journal of Quality in Health Care 14(2): 12–17.

Morris J, Murphy K, Mor V, Berg K, Moore T. Validation of Long-Term and Post-Acute Care Quality Indicators. Final Draft Report, August 2, 2002. CMS Contract 500-95-0062.

Phillips C, Zimmerman D, Bernabei R, Jònsson D. 1997. Using the Resident Assessment Instrument for Quality Enhancement in Nursing Homes. Age and Ageing 26 (Supplement 2): 77–82.

Zimmerman DR, Karon SL, Arling G, Clark BR, Collins T, Ross R, Sainfort F. 1995. Development and Testing of Nursing Home Quality Indicators. Health Care Financing Review. 16(4): 107–27.