Hard data: get a handle on your facility database.

Administrators and corporate operational professionals often ask me where they should place their focus. I tell them, "Focus on the quality of the facility's database!"

Your facility database controls the success of your operation, produces regulatory and payment risk or success, and directs the management approaches to produce quality services with both clinical and financial outcomes. Yet too frequently in nursing homes the production and transmission of facility data is delegated to an individual with no power or expertise to create a quality database.

As an operational consultant, I am weary of talking to senior managers about the data collection, reporting, and review process. Some don't seem to understand the basics of the Minimum Data Set (MDS) system, the amount of training and education MDS coordinators need to function, and the operational risks they face with inaccurate data, inappropriate Resource Utilization Group (RUG) scores, and incorrect quality indicators/quality measures (QI/QM).

There are four issues managers need to address to decrease risk and improve operational success driven by the database:

1. Know the content of your facility database.

2. Know who sets assessment reference dates (ARD) and tracks when a resident is in an assessment reference period--this is the data collection window.

3. Expose the problems with documentation and data collection as operational issues--not clinical issues.

4. Identify the role that the therapy department has in data collection and documentation and in the overall MDS process. Remember that the majority of Medicare payment is for rehab services.

Know thy database

The first step to knowing the content of the database is to review reports that are available through official agencies. These include the QI/QM reports and standard reports from the state. This is just the beginning.

Facility managers should be able to create reports from their facility data repository to track clinical and rehab outcomes, RUG categories, and activities of daily living (ADL) scores. They should then focus on payment groups, rehab utilization within those payment groups, MDS completion statistics, and the types of MDS documents they produce. Doing so ensures proper staffing for the data reporting process and other data focus reports depending on the service platform of the organization.

Wield data as an operational performance indicator as well as outcome documentation, both clinical and financial. Your software programs should have open architecture--that is, they should allow you to customize your reports so they can be as specific as possible.

Harnessing MDS data

All data for the MDS are collected during residents' individual assessment reference periods, and everyone in your facility should be able to find out for which residents staff are actively collecting data at any given time.

Staff need to set ARDs with the individual characteristics of the resident in mind. Too often, one department or discipline will dominate the ARD process, and the facility will not have the best data collection window for the case. Managers must focus on the process for setting ARDs and encourage interdisciplinary involvement and flexibility in setting the dates, keeping in mind the rules for this process in the Resident Assessment Instrument (RAI) User's Manual.

Speak my language

Senior managers need to address documentation problems as an operational issue. The documentation in the record drives the database--therefore, lack of training or resources at the point of documentation can distort the database.

The language of the MDS must become the documentation language of the facility, wherever possible. That means administrators need to know the language as well and have a copy of the RA/User's Manual in their office. Forms and formats for documentation should have MDS terminology as a criterion, and time frames need to be consistent with assessment reference periods. As F-Tag #272, Comprehensive assessments, advises, the assessment needs to be reproducible in the record. The language needs to be the same. A breakdown in that critical step remains one of the biggest issues the industry faces today.

I see these as foundational issues that play out in facilities all across the country. The data problems are the same everywhere, and the risks are increasing rapidly. Database accuracy is an operational issue, and senior managers must learn the ropes in this area to effectively manage their operations.

BY LEAH KLUSCH, RN

RELATED ARTICLE: The role of therapy in data collection.

Because such a high percentage of Medicare cases involve therapy, we must identify the role that therapy has in outcome reporting.

The Resource Utilization Group (RUG) 53 system assists us with this by tracking the amount and frequency of therapy and the activities of daily living (ADD scores during a resident's stay. The data should document outcomes with changing levels of therapy, as well as ADL scores, as the resident becomes stronger and more independent.

Conduct a quick audit of your therapy department by doing the following:

* Pull a dated RUGs report for reference; 60 days is a good time frame to use.

* Review Medicare Part A cases by looking at the RUGs for sequential MDS documents (i.e., the five-day, 14-day, 30-day, and 60-day reports).

* If the RUG levels don't change or if therapy levels stay very or ultra high and then suddenly stop, for example, check the outcomes of the therapy interventions.

This is just an initial level of review, but it is an excellent place to start, It's a good idea to do regular audits on therapy days and minutes using the care delivery records from frontline staff as a reference.

I also suggest checking how many therapy staff can say that they have read and understand all of the therapy minute coding clarifications in the Resident Assessment Instrument User's Manual. Accuracy of reporting in this area is essential because it affects so much of your payment. The documentation needs to be unfailingly exact because errors in this area can quickly distort your data or affect outcome reporting.

--Leah Klusch, RN

BY LEAH KLUSCH, RN

Leah Klusch is the executive director of Alliance (OH) Training Center and a nurse educator and operational consultant who brings more than 40 years of experience to her work. She can be reached at the Alliance Training Center at 330/821-7616.