The power of the MDS: quality indicators shouldn't be feared--they are a useful resource. (Feature Article).

The Minimum Data Set (MDS)--there aren't many aspects of nursing home operations with the power of this tool. This is the form that drives regulatory and reimbursement activities, and now it even provides information to consumers about the care provided in individual nursing homes. Yet with so much focus on the regulatory and reimbursement aspects, the power of the MDS to improve resident care often goes unnoticed. That power is inherent in the Quality Indicators (QIs).

The QIs have been an integral part of the long-term care survey process for many years, and facilities often view them as dreaded liabilities. However, in skilled hands they've proven to be built-in resources for continuous quality improvement--valuable tools that have improved resident care and survey outcomes.

A recent report by the Office of Inspector General of the Department of Health and Human Services found that although nursing homes generally collect an array of information to help them identify problems, many facilities often don't know how to use the data to effect positive change. But in this era of increased resident acuity coupled with intensified scrutiny of nursing homes by consumers, regulatory agencies, advocacy groups, and the media, it is critical to be able to identify and troubleshoot problems early. That means identifying potential quality problems before they become trends, making system changes to prevent problems from recurring, and continuously monitoring systems to validate their effectiveness. The QIs are ideal for this task.

The 24 QIs were developed as the foundation for a national analytic reporting system based on MDS data. They also form the basis for the three sentinel health events that trigger investigation during a survey, even if the event occurs only once: prevalence of fecal impaction, prevalence of dehydration, and prevalence of pressure ulcers occurring in low-risk residents. Although the QIs provide surveyors with a wealth of information about resident care, they are required to validate QI data through on-site record review, observation, and interviews with residents and staff.

Surveyors have mastered the use of the QIs as clues to quality of care; the same opportunity is available to providers. The key to a facility's success in using QI data effectively is in accurately interpreting and analyzing QI reports, avoiding pitfalls related to the underlying MDS coding, and taking action to minimize risk. QI calculation is based on a ratio expressed as a fraction. For example, the calculation for the prevalence of fecal impaction QI, is simple enough: If item H2d, fecal impaction, is checked on the MDS, that MDS contributes to the numerator. The denominator consists of all residents on the most recent assessment. In this case, it is the definition of "fecal impaction" for MDS coding that must be monitored for accuracy. The definition is hard stool on digital rectal exam, or stool is seen on abdominal x-ray in the sigmoid colon or higher. If the resident's condition does not precisely meet this definition, then fecal impaction should not be checked on the MDS. In terms of minimizing risk for this QI, the facility should ensure that the MDS nurse understands the coding rules; implement clinical systems to prevent impactions, including an effective system for documenting bowel movements; and develop quality-improvement processes for monitoring systems.

Dehydration is another high-risk area of resident care. In this case, the QI is based on MDS item J1c, output exceeds input, or a diagnosis of dehydration entered at item 13. Accuracy of intake and output (I&O) records is a key pitfall for this QI when it comes to MDS coding. Facilities should implement hydration-management programs that include clear policies and procedures regarding admission and ongoing risk assessment, identifying resident conditions that require I&O monitoring, and routine monitoring of the accuracy of the I&O data. Hydration-management programs should include specific interventions for preventing dehydration in the general population, as well as provisions for implementing care plans specific to high-risk residents.

Some other QI hot spots that can be effectively managed include:

* Bladder or bowel incontinence without a toileting plan. All incontinent residents who are not severely cognitively impaired by the QI definition must have a toileting program with preplanned, scheduled toileting.

* Decline in late-loss ADLs. This QI looks at bed mobility, transfers, eating, and toileting, and compares the previous and most recent MDSs. It goes to the heart of the marching orders for nursing homes: To assist the resident "to attain or maintain the highest practicable physical, mental, and psychosocial well-being." Therefore, it is critically important to have reliable communication systems with bedside nursing staff so that ADL declines are identified and treated when they occur, rather than as a result of the next scheduled MDS assessment. By then, it often is too late to slow or reverse the problems.

* Daily physical restraints. This MDS item (P4) is often overcoded because of a misunderstanding of the definition of "restraints." Instead of coding for the objective presence of restraints, the assessor must identify the effect the restraint has on the resident. For example, if the resident could get out of a wheelchair if the lapboard or belt restraint was not in place, then the lapboard or belt restraint meets the definition of a restraint. If the resident would not be able to get out of the wheelchair in any case, then the device is not a restraint for that resident. Failure to accurately identify a device as a restraint can lead to survey deficiencies.

Management of critical processes is the key to success. Ensuring the accuracy of the MDS data is at the top of the list, since all of the QI results are based upon it. There is no substitute for formal, reliable, ongoing training for the MDS nurse and the interdisciplinary team. In addition, routine internal and external auditing can identify MDS coding errors before they cause problems.

Monitoring and analyzing online MDS reports also provide valuable information for checking MDS processes. They are available through the state intranet and include:

* Error Summary. Lists warning errors, including the number of times each occurred and the percentage of assessment with each error

* Monthly Submission Statistics. Provides the number of records processed, rejected, accepted, and the rejection percentage

* RFA Statistics. Lists all assessments accepted into the database by assessment type

* MDS Missing Assessment Report

In addition, monitoring and analyzing each QI can help to solve resident-care-system problems. To conduct this analysis:

* Select QIs for review based on the percentile rank and previous deficiencies. Look at any QI at 75 or above.

* Review the care and documentation of each resident relative to the QI.

* Draw conclusions about the quality of care.

* Decide if the identified problem is isolated or facility-wide.

* Report findings to the quality assessment and assurance committee and develop an action plan for improving the underlying system.

* Monitor future QI reports to determine the effectiveness of the improvement plan.

* Routinely monitor key aspects of the resident-care systems involved to ensure that the systems are still effective.

It is not possible for a facility to monitor all aspects of resident-care systems at all times. For some, keeping an eye on this many complex systems is so overwhelming that it becomes paralyzing. That's why using the QIs makes so much sense: The data provide the clues needed to determine priorities in the constant task of identifying systems that might not be functioning properly--and identifying them before the problems reach crisis levels.

Rena R. Shephard, RN, BA, FACDONA, is president of the American Association of Nurse Assessment Coordinators and of RRS Healthcare Consulting Services in San Diego. For more information, phone [phone] or fax [phone]. To comment on this article, please send e-mail to [e-mail].