Using MDS Data to Know the Facility

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n November 12, 2002, Health and Human Services (HHS) Secretary, Tommy G. Thompson, launched the Nursing Home Quality Initiative for all Medicare and Medicaid certified nursing homes. This initiative combines new information for consumers about the quality of care provided in individual nursing homes with important resources available to nursing homes to improve the quality of care within their facilities. The national launch follows a six-state pilot project (Colorado, Florida, Maryland, Ohio, Rhode Island, and Washington) that began in April, 2002.
       HHS's National Nursing Home Quality Initiative1 is a four-pronged effort consisting of:
1. Center for Medicare and Medicaid Services' (CMS) continuing regulatory and enforcement efforts conducted by state survey agencies. According to CMS, the survey process will not change as a result of the Quality Initiative.
2. Improved consumer information on the quality of care in nursing homes. CMS is in the midst of a publicity campaign to promote the new Quality Initiative. The ads, appearing on television and in newspapers, supply information about select quality measures and encourage visits to Medicare's consumer website at http://www.medicare.gov or calls to 1-800-MEDICARE to obtain the complete quality data. Additionally, in its efforts to provide consumer information, CMS now has available "A Guide to Choosing a Nursing Home."
3. Continual community-based, quality improvement programs offered to nursing homes by Medicare's Quality Improvement Organizations (QIOs). QIOs (formerly known as Peer Review Organizations or PROs) are CMS contractors that, over the past decade, have offered improvement assistance to hospitals, physician offices, and in some states, nursing homes. Their mission is to ensure the quality, effectiveness, efficiency, and economy of healthcare services provided to Medicare beneficiaries. As part of the Quality Initiative, the QIOs are expanding their scope by providing information and consultation to skilled nursing facilities in all states. To learn more about QIOs' expanded role and the resources they offer, visit the QIO website (http://cms.hhs.gov/qio/).
4. Collaboration and partnership to leverage knowledge and resources. QIOs and state and local long-term care ombudsmen will use the new data as "one piece to the puzzle" when helping families make informed decisions about placement into nursing homes. Visit the ombudsman website (http://www.ltcombudsman.org) for details of their quality initiative efforts.

Overview of the 10 Quality Measures
       In all, there are 10 quality measures (QMs) that are split into two categories--six measures for long-term stay residents (residents in the facility for 90 days or more) and four measures for short-stay residents (residents in facilities less than 90 days) (see Tables 1 and 2).
       All QMs are directly based on the facility's data recorded on the Minimum Data Set (MDS) 2.0. The definitions for each QM and the MDS items that are considered in the definition are provided in the Quality Measures for National Public Reporting User's Manual. The manual can be downloaded from the CMS website (http://www.cms.gov/providers/nursinghomes/nhi/NatlUserMan_v1_1.pdf). Additionally, Frequently Asked Questions (FAQs) related to the Quality Initiative are posted on the CMS website (http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php) (Category: "Providers" and Subcategory "Nursing Home Quality Initiative").

Data and the Quality Measures
       With the implementation of CMS's Quality Initiative, comparative data on the quality of care in long-term care facilities is available to the public. Beneficiaries, families, hospital discharge planners, case managers, and reimbursement agencies--basically every customer and prospective customer--can "log on and look in" to data provided by the facility. The following ideas, although not an exhaustive list, may help facilities in preparing for any changes consequent to the Nursing Home Quality Initiative:
       Educate. Include administrative staff, admissions staff, direct care staff, interdisciplinary assessment team, residents, families, and possibly referral agencies. Explain the quality measures, factors that affect the quality measures, and how to interpret the data. Make clear that your facility's data may deviate from the state average for various reasons, many of which are not a reflection of the quality of care provided within the facility. For example, a facility with a high percentage of pressure ulcers may specialize in wound care or may admit a high percentage of hospital patients--who are usually clinically complex and nutritionally compromised--and because of this, pressure ulcer development may be clinically unavoidable for these patients.
       The QMs are only as accurate as the MDS data behind them. Remember, the measures are extracted from MDS responses; therefore, accurate MDS responses are as important as ever. Each MDS team member must understand the coding definitions and instructions for completing MDS items as given by CMS. The definitions are provided item by item in the Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual. Revisions and updates to MDS item definitions and instructions are posted on the CMS website (http://www.cms.gov).
       Yes, everyone makes mistakes; but there is little room for error in this climate. Determine whether the facility's software provides MDS alerts and analytical MDS reports prior to submission of MDS data. By analyzing MDS data, the facility can detect and correct possible errors while the data is still in house. If errors are detected on transmitted data, the facility should investigate the problem areas and correct erroneous data according to the CMS correction policy.
       Explore the Continuous Quality Improvement (CQI) capabilities of the facility's computer software. Does the software provide useful reports on the facility's MDS quality indicators, including the new CMS QMs? If so, is the CQI team using the software to maximize information? Are CQI reports distributed timely and to the appropriate staff members? Do CQI team members know how to analyze the information and effectively implement appropriate, well-timed corrective actions?
       Survey the facility's proactive and reactive strategies to deal with each of the QMs. Proactive strategies are those steps taken to prevent emergence of problems. Reactive strategies are actions taken to manage problems if and when they emerge. These overlapping strategies include:
- Staff training to prevent and manage the QMs
- Adequate staffing levels
- Sufficient supplies and resources
- Written policies and procedures to prevent and manage the QMs that are according to current, accepted standards of care
- A robust documentation system that captures the proactive and reactive services given by the facility
- Comprehensive assessments that assess the resident's needs, strengths, and preferences
- Individualized care plans with the goal of promoting the resident's highest practicable level of well being
- Effectual CQI programs that assure ongoing compliance.

Conclusion
       While it is not possible to predict the full impact of the Quality Initiative on consumers and facilities, it is certain to change the dynamics. The use of MDS data does not automatically result in knowledge about the quality of care within a facility; nevertheless, it does provide decision-making potential for both consumers and facilities.