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s a consultant and educator, I have had many requests for information and materials related to clinical practice guidelines, regulatory processes, and documentation standards. Facilities are surprised when I mention the global responsibilities of the medical director as I give them specific information about their requests. While teaching educational programs to interdisciplinary audiences, the highlights from the Minimum Data Set (MDS) 2.0 manual that speak to the role of the attending physician and medical director always bring looks of surprise from the participants. Why is this? The answer is not simple and is frequently complicated by the demographics of the facility, the clinical issues, and the historical role and perception of the role of medical direction.
       When I refer to the regulatory information and the documentation in the MDS 2.0 manual, the roles of the attending physician and the medical director are plainly stated. In chapter 1 of the MDS 2.0 manual, section 1.13, Sources of Information for Completion of the MDS, it states that the following sources of information—–one of which is communication with the resident’s physician—must be used in completing the MDS: “The physician’s role is central to the overall management and outcome of resident care…Review the MDS with the resident’s attending physician to share and validate pertinent information. If there is difficulty obtaining information or input for the assessment from the attending physician or the transferring institution, the facility’s medical director should be asked to intervene.” This is a very direct, clear quote about the involvement of the physician and the medical director related to a frequent problem facilities face related to the accuracy and adequacy of information they receive from transferring institutions at the time of admission and during the stay as MDS documents are completed.
       The role of the medical director is described in the federal regulations tag # 501, which states, “The facility must designate a physician to serve as medical director. The medical director is responsible for implementation of resident care policies and the coordination of medical care in the facility.” The rules have a list of policies that need to be reviewed and implemented including admissions, transfers and discharges, infection control, use of restraints, physician privileges and practices, as well as the responsibilities of nonphysician healthcare workers. Facilities should review this list and be certain that the medical director has reviewed the current policies.
       In addition to the basic policies, the medical director is also responsible for policies related to accidents and incidents, ancillary services, use of medications, use and release of clinical information, and overall quality of care. This requires the facility to communicate with the medical director about arrangements and policies involving laboratory, radiology, and pharmacy services.
       The medical director also has a coordination role that makes him or her responsible for assuring that the facility is providing appropriate care and physician services for the residents. This begins with an active, open communication between the direct care staff and nursing administration when problems are identified and documented. The medical director should be an active participant in the management structure of the facility and the documentation of quality assurance programs, specific communication with physicians, and observations of residents’ outcomes and care delivery patterns. In their recommendations for medical directors related to tag #501, the American Medical Directors Association (AMDA) suggests that medical directors do the following: “Evaluate questions and concerns about the care of individual residents and discuss findings with residents, families, staff, and attending physicians, as pertinent. Assess care on rounds and via record review. Actively advocate for improvements in the overall quality of care. Document personal efforts to improve care, especially as part of the quality assurance process.” Facilities should take this information to their medical staff and medical director for discussion and policy action.
       AMDA has an excellent document called “Synopsis of Federal Regulations in the Nursing Facility: Implications for Attending Physicians and Medical Directors, Revised January 2003,” which is available at http://www.amda.com and can be used as an information source and discussion outline. In this document, federal regulations that implicate the attending physician and the medical director are documented with recommendations for action by the association. Facilities should secure this document and review their internal policies and the function of their current medical director with the parties involved. The surveyors are only one group of external evaluators to whom the facility must answer. Risk management and corporate compliance guidelines should be addressed, as our payers (both governmental and private) and the legal community will be making assessments of the role of the attending physician and the medical director in individual cases and overall facility performance. AMDA also has many practice guidelines focused on primary care delivery and practice issues related to residents in post-acute care facilities available to its members. The practice guidelines offer facilities a structure for education of their care delivery teams and a reference when practice issues are discussed with physicians. Standards of practice must be a part of quality medical care and policy development. The medical director is responsible for this, and the facility can provide membership to the professional association as well as copies of these guidelines and information as part of their support to the physicians care for their residents.
       The medical director has responsibilities that relate to many of the federal rules impacting the long-term care facility. Administrators and directors of nursing should have an open, active communication with their medical director regularly to discuss quality of care issues, policy development and revision, and quality assurance activity. Documentation of these meetings as well as case- or issue-specific discussions must be maintained to show the level of interaction and involvement the medical director has in the management of the care in the facility. As acuity levels increase and the regulatory system becomes more specific, the level of interaction between professionals must be demonstrated to show that the rules are being addressed. The role of the medical director is pivotal to proper care delivery and facility practice. The care delivery, regulatory, and legal environments are changing, requiring more interaction between the medical director and the facility staff. This must begin with awareness of regulatory requirements and the status of policies and procedures in the facility, building a framework of responsibilities and defining the role of the medical director with the administration and clinical staff.
       Facility managers must look at the role of the medical director, communicate the regulatory requirements, and move to establish expectations for the job duties. Clinical staff must communicate issues and problems as well as the need for policy development and revision to the medical director. Practice issues need to be documented and referred to the medical director for action. Attending physicians should be aware of the requirements and standards they must address. Medical directors should be encouraged to participate in AMDA and use the practice and regulatory guidelines established by this group as a baseline. Facility administrators must be proactive to be certain requirements are met and care delivery practices are current. The relationship with the medical director is a very important part of this process.