If your Facility-level and Resident-level MDS 3.0 Quality Measures (MDS 3.0 QM), the Skilled Nursing Facility MDS 3.0 Quality Reporting Program Quality Measures (MDS 3.0 SNF QRP QM), or Five Star QM reporting on Care Compare are missing the mark and your scores are not what you expect, you have a great opportunity to examine facility policies and practices that impact how these quality measures (QMs) are calculated. Lagging or poor QMs reflect specific processes in a facility that need to be reviewed and revised. We are going to look at a few areas to consider that may be impacting QMs.
Staffing and Quality Measures
Staffing levels impact QMs – in units that are chronically understaffed, QMs may reflect increased incidence of UTI, decline in ADL, new or worsened incontinence of bowel or bladder, increased incidence of or worsening pressure injuries, increased incidence of weight loss, depressive symptoms and/or behaviors affecting others, psychotropic medication use, falls, and falls with major injury. Understaffing can also result in increased resident ER visits and hospitalization/rehospitalization rates. These issues are reflected in facility and resident-level MDS 3.0 QM; some of these issues are also reflected in the MDS 3.0 SNF QRP QM. When working to improve QMs, a review of staffing patterns – even when staffing meets the minimum threshold required – may reveal gaps in coverage, such as during shift change or during other specific time periods when gaps in staffing or reduced staffing can lead to increased risk to the resident care or safety. Chronic short staffing impacts job satisfaction, may result in staff burn-out or compassion fatigue, and can lead to increased staff turnover, all of which impact continuity of care. Gaps in continuity of care can directly result in declines in QMs.
Staff Training and Quality Measures
Specific staff training – or lack of training – to care for your resident population impacts QMs. Routine staff training and competency testing is necessary to manage specific resident conditions in your facility. Regular training supports quality care and helps reduce hospitalization as staff develops the ability to recognize and report changes in condition early and can implement interventions in-house. Staff training may also include how and when to utilize specific documentation tools to accurately reflect the care provided, interventions implemented, and appropriate notifications of changes.
With appropriate training, the interdisciplinary team (IDT) can engage and utilize support from employees other than the nursing and therapy staff. Use of non-licensed staff who have been trained to provide some support to licensed or certified staff can extend staff capability. Staff who do not provide direct resident care could be included in trainings that facilitate communication of changes they see in residents on a day-to-day basis. For example, housekeeping, dietary, transportation, and maintenance staff could be included in training for behavior management and dementia care to support resident safety and optimize care planning, which may lead to decreased falls, decreased incidence of weight loss, and behavior management with non-pharmacological interventions. Use of paid nutritional assistants for meal assistance and/or group activity support opens opportunities to engage residents who are at high risk for falls, support participation in activities, and encourage hydration in residents who may need increased 1:1 or small group attention.
MDS and Quality Measures
Nearly every data item on the MDS is used in some capacity to calculate QMs – from causing the resident to be included in the numerator or denominator of the QM calculation, to exclusions and covariates that risk adjust QM calculations for the facility-level statistics. Routine IDT review of the Resident Assessment Instrument Manual (RAI Manual) requirements to schedule the MDS, capture data via resident interview and in the health record, and complete the MDS correctly helps support MDS accuracy, which ensures that QMs are an accurate reflection of care. A periodic review of the examples of coding scenarios provided by Centers for Medicare and Medicaid (CMS) in the RAI Manual can also help support accurate MDS coding. Independent audits of MDS completion can help identify inaccuracies in MDS scheduling and coding practices that can impact QMs.
Resident Records, Resident Interviews, and Quality Measures
Facility-level and Resident-level MDS 3.0 QM and the MDS 3.0 SNF QRP QM are calculated using data captured on the MDS at specific points in time. Both the MDS 3.0 QM and MDS 3.0 SNF QRP QM are derived from and calculated using many of the same data elements on the MDS; each program has specific requirements per CMS that determine when the data is collected, how each measure is calculated, and how the QMs are reported. If supporting documentation is not available in the record or interviews are missed during the look-back period, those MDS items are captured as “–”, or “dash-coded,” which indicates to CMS that no information is available in the record to code those items. Dash-coded MDS items impact how QMs for that resident are calculated and reported – missing (dash coded) MDS information causes those QMs to be excluded from the facility-level and resident-level QM count. Missed data and interviews can happen for a variety of reasons, including staff misunderstanding of the requirements, unplanned discharges, or incomplete data collection in the record. It can be helpful to complete resident interviews early in the lookback period, rather than closer to the Assessment Reference Date (ARD). It is also necessary to have a reliable process in place to capture the required MDS data elements in the health record during the correct look-back period.
CMS periodically changes data elements on the MDS, and these changes are usually published just prior to implementation on October 1 of every year; missing or overlooking these changes can impact data collection in the health record or result in inaccurate/incomplete interviews. To avoid this, data collection tools need to be updated in preparation for October 1 changes, and IDT members who are responsible for using the new tools should be educated about the changes. Staff responsible for MDS interviews and completion should also be trained per the RAI manual as changes occur. Auditing MDS completion with a focus on updates following October 1 changes will help ensure that facility reporting to CMS via the MDS (and resulting QM calculations) follows the correct coding requirements and RAI instructions.
Summary
Improving QMs is not a quick process, and the best outcomes involve careful evaluation of all possible reasons that a QM is flagging. Practices that foster QM improvement include:
- Adequate staffing with appropriate training to promote quality care.
- Accurate documentation of resident conditions and cares to support what is captured on the MDS.
- Specific training to reinforce correct MDS completion and avoid dash coding data elements on the MDS that impact QMs.
- Audits of MDS completion to provide feedback and direction for staff training when MDS data capture is inaccurate or requirements change.
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