Refocusing the nursing staff for PPS success.

This project scrutinized and improved nursing processes and documentation

While the details of a Medicare Prospective Payment System (PPS) are being developed, many workshops are being held to speculate on how it will be implemented at the facility level. These workshops are basing information on what has been done in the RUGs III demonstration project. Unfortunately, what has been done varies from one demonstration state to the other, from one intermediary to the other and, in some instances, does not coincide with the written regulations for the demonstration project. What's more, caregivers in some facilities are so focused on or distracted by the mandate for automation that the question could legitimately be asked, "Where is the patient in all this?"

Meanwhile, the literature reporting positive outcomes relating to nursing care is scant. Indeed, documentation scrutinized for the past four years by the author and cohorts in many facilities across the country revealed positive outcomes in nursing documentation to be almost nonexistent. The questions arise: "Were positive outcomes achieved and not documented?" or "Were positive outcomes not being achieved (and, if not, why not)?" This leads to the big question: How will the distractions of increased numbers of MDSs to complete and transmit to states, computerization, and confusion about new documentation for reimbursement affect nursing care delivery and the achievement of positive outcomes?

Caregivers and providers seem distracted specifically by such issues as "Which MDS categories are weighted for the best reimbursement rate?" and "Who should actually do the MDS?" Many questions seem to focus on computer software problems. While these are important issues in need of resolution, the more important question to be resolved may be "How can nursing care be delivered more effectively without increasing staffing, while documentation accurately captures information necessary for appropriate reimbursement?"

While this article does not intend to imply that increasing nursing staffing is the answer (it probably is not), the following numbers should encourage providers to look very closely at how nursing time was and is spent. For example, the facility that staffs with four nursing hours/patient/day really offers approximately only 13 minutes of RN/LPN time per patient shift, once one has subtracted 2/3 of the time for CNA time and 50% of RN/LPN time for administration of medications. The remaining 13 minutes is available for nursing management of actual and potentially unstable conditions through assessment, physician consultation and implementation of new orders. Additionally, time is spent doing treatments, supervising nursing aides, counseling families, documenting, doing MDSs and care plans, etc., etc. And how much time is wasted by nurses answering the phone, emptying wastebaskets, completing redundant forms, doing housekeeping and performing dietary tasks? This, too, is worth exploring.

Begin the exploration with this question: Is the nurse the appropriate person to be doing the data input, or should the scant amount of nursing time available be focused on more accurate and extensive patient assessment so that subtle changes can be identified and proper action taken? When these data are clearly documented in the medical record, could not a well-trained clerical person retrieve the data needed for the MDS completion, with a nurse doing the final review before transmission?

As mentioned earlier, based on the published literature available, the relationship between nursing care and positive outcomes has not been clearly illustrated. Additionally, there is little in the published literature to describe the methods, processes and systems of nursing care delivery that achieve more positive outcomes.

According to Smith (see "Suggested Reading"), positive patient outcomes related to nursing care were increased more than 700% (from 8% to 63%) in one facility within one year by revising and refocusing the nursing role. In this project, nursing staff was not increased to achieve these results. The four major phases in this role-revision program were:

1. Freeing up nursing time by task shifting. This involved exploring how nurses spent their time during an eight-hour shift, focusing specifically on clerical, housekeeping and laundry functions.

2. Refocusing time on the nursing process - i.e., assessment, problem identification, care plan development, care plan implementation and ongoing revision of the plan to get results. This involved showing nurses how to do an in-depth assessment, approximately identify problems and develop a useable care plan (useable especially in day-today care and outcomes measurement). Job specifications were rewritten and performance evaluations refocused, as well.

3. Providing education/training in critical thinking to encourage focusing on outcomes, as opposed to simply passing medications and going through basic nursing task completion.

4. Assigning accountability to individual nurses, specifically, a patient case load for which the nurse is accountable for timely assessments and MDS completion. The nurse is responsible for the case load over the long term.

Recent results (1997-1998) from this "role revision" program revealed the following "before and after" results in a 20-bed, hospital-based skilled nursing facility (subacute unit) in the Midwest:

Problems Identified by Nurses Before Nursing Role Revision (Charts 1-5)

Chart #1

Problem(s) identified by facility nurses included:

* Potential for falls related to unsteady gait

The actual problems evident to the author when the medical record was scrutinized included:

* Potential for or actual nutritional/hydration deficits necessitating a gastrostomy tube; and

* Impaired skin integrity evidenced by open, foul-smelling areas on both heels

Chart #2

Problem(s) identified by facility nurses included:

* No care plan found

The problems evident to the author when the medical record was reviewed included:

* Impaired circulation related to severe peripheral vascular disease 

* Alteration in nutritional status, i.e., malnutrition and anemia

* Impaired mobility related to a recent below-the-knee amputation 

* Pain related to recent amputation

* Ineffective coping, i.e., depression

Chart #3

Problem(s) identified by facility nurses included:

* Memory deficit was the only problem identified on actual care plan.

The actual problems evident to the author on medical record review (in fact, the medical history and physical were missing, and the information was found only in nursing notes) were:

* Pain related to recent knee surgery and inflamed toenails

* Impaired mobility related to knee surgery and inflamed toenails

Chart #4

Problems identified by facility nurses on the existing care plan included:

* At risk for injury, as seen by getting out of bed unattended (problems were not always appropriately stated)

* Poor oral intake

The actual problems evident to the author on medical record review which should have been on the care plan included:

* Back pain, etiology unknown

* Ineffective coping, i.e., severe depression

* Impaired mobility and self-care deficit related to general weakness

* Possible alteration in nutritional/hydration status evidenced by weight loss

* Potential systemic infection related to indwelling bladder catheter (no reason was found in the record for the catheter)

* Possible unstable neurologic status related to changes in Dilaudin dosages

Chart #5

The only two problems found on the care plan by facility nurses were:

* Potential for falls related to unsteadiness

* Oral intake not meeting the patient's nutritional needs

The actual problems evident when the medical record was reviewed by the author and which should have been on the care plan included:

* Potentially unstable medical condition related to recent surgery for gastrointestinal bleeding 

* Cardiorespiratory instability related to chronic obstructive pulmonary disease, congestive heart failure and coronary artery disease, evidenced by 4+ edema, elevated B/P, chest pain and dyspnea 

* Impaired skin integrity related to abdominal surgical incision

Problems Identified by Nurses After Nursing Role Revision (Charts 6-10)

Chart #6

Based on the authors' chart review of the medical history and physical, the patient had pain related to a recent below-the-knee amputation, secondary femoral/popliteal circulatory occlusion and impaired mobility related to the amputation.

Problems identified by facility nurses on the actual care plan included the following:

* Potential for nonhealing surgical site related to history of poor circulation

* Alteration in skin integrity related to surgical incision

* Potential alteration in nutritional status related to poor appetite, i.e., consuming less than 50% of daily diet

* Impaired physical mobility related to below-the-knee amputation, right-sided weakness and right hand contracture 

* Alteration in comfort related to recent surgery

The facility had identified all pertinent problems obvious to the reviewer plus other more subtle, but important, problems.

Chart #7

Problems evident based on the author's review of the medical history and physical included potential gastrointestinal complications related to recent bowel obstruction which necessitated surgery, pain related to surgery and potential nutritional/hydration deficits related to recent bowel surgery.

Problems identified by facility nurses on the actual care plan included:

* Possible unstable medical condition related to recent bowel surgery evidenced by hypoactive bowel sounds 

* Altered nutritional status and potential dehydration related to recent bowel surgery

* Impaired skin integrity evidenced by surgical incision

* Potential for impaired mobility related to generalized weakness

* Alteration in comfort related to recent abdominal surgery

* Potential ineffective coping related to health problems evidenced by anxiety

Again, all of the obvious health deficits identified by review of the medical history and physical were identified by nurses, as well as other more subtle but important potential problems.

Chart #8

The author's review of the medical history and physical revealed cognitive and mobility deficits possibly related to a recent undiagnosed CVA, insulin-dependent diabetes and hypertension.

The problems identified by facility nurses on the actual care plan were:

* Unstable medical condition with evidence of left-sided weakness possibly related to a stroke

* Unstable medical condition related to diabetes (which should have been stated as a "potential" problem)

* Impaired mobility and self-care deficit related to left-sided weakness secondary to a stroke.

The only problem that could have been addressed but wasn't found on the actual care plan was the cognitive deficit, which could possibly have improved with intervention by a speech therapist. Otherwise, all obvious problems were addressed.

Chart #9

The author's review of the medical history and physical revealed a heart attack two weeks previous to this admission, with blackout spells. The patient was admitted to rule out cardiac problems and/or mini-strokes.

The actual problems identified by facility nurses on the care plan were:

* Unstable medical condition related to cardiac disease (episode of ventricular tachycardia) evidenced by syncope 

* Alteration in medical condition related to possible gastrospasm, evidenced by nausea and vomiting (this problem might have been inappropriately stated)

* Potential alteration in elimination as evidenced by indwelling catheter (this problem would have been more accurately stated as "Alteration in urinary elimination with risk of infection related to indwelling bladder catheter")

* Tolerates only 15 to 30% of meals (this problem could have been more appropriately stated as "alteration in nutritional/hydrational status related to poor dietary intake"

* Impaired mobility related to deconditioning

While some of the problems identified by facility nurses were not stated as clearly and accurately as they could have been, all of the pertinent problems were identified except for the possibility of neurologic disorder, i.e., mini-strokes.

Chart #10

The author's review of the medical history and physical indicated that this patient had been struck by a car and sustained multiple abrasions and contusions as well as a fractured knee and ribs. The history also included some past problems with renal failure and hypertension.

The problems identified by facility nurses on the actual care plan included:

* Impaired circulation related to surgical repair of knee fracture and cast application (this probably would have been more appropriately stated as a "potential" problem)

* Potential for infection related to a subclavian catheter (intravenous catheter inserted into one of the large central vessels)

* Potential for unstable medical condition related to a low hemoglobin (blood count)

* Alteration in nutrition related to poor oral intake

* Potential for impaired skin integrity related to decreased mobility and long leg cast

* Alteration in bowel elimination evidenced by constipation

* Alteration in pattern of urinary elimination related to Foley catheter 

* Limited mobility related to fractured knee

While many appropriate problems were identified, problems related to pain and possible respiratory complications related to the rib fractures could have also been addressed.

In the remainder of the 15 charts reviewed, the "before role revision" charts indicated similar omissions of patient problems, raising patient care concerns as well as reimbursement issues. If problems are not accurately identified, how can appropriate interventions be prescribed for problem resolution and documented for reimbursement purposes?

In contrast, after phases I and II of the role revision program were implemented, significant improvement was seen in the nurses' ability to identify pertinent patient problems and address them on the care plan. However, implementation of the care plan and documentation of positive outcomes have just begun and are yet to be evaluated. The assignment of a nurse to a specific case is expected to improve the actual implementation of the care plan, and documentation is expected to reveal increased positive patient outcomes, at the completion of the role revision project in progress at this facility.

In conclusion, after working with this nursing role revision program, which was statistically evaluated to increase positive outcomes without increasing nursing hours, the author highly recommends role revision. There is one thing we do know about the future: No matter what reimbursement system SNFs are challenged to work within, nurses must achieve better outcomes more efficiently, and document them more clearly, accurately and concisely. In order to accomplish this, a major change in the way we have delivered care in the past is essential.

Suggested Reading

Smith J. Changing traditional nursing home roles to nursing case management. Journal of Gerontological Nursing 1991;17(5): 32-39.

Judy Smith, GNP, RN, CS, is a consultant with Solomon HealthCare Consulting, Denver, CO. For further information, [phone].