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n this article, we will address the Quality Indicator/Quality Measure (QI/QM) reports that are generated weekly. As you know, the Centers for Medicare & Medicaid Services (CMS) developed a draft of the Revised Facility Guide for the Minimum Data Set (MDS) QI/QM reports, effective July 17, 2005. It helps to refer to this information when evaluating the QI/QM reports. (To download the final version of the guide, visit https://www.qtso.com/mdsdownload.html.) The guide is divided into 5 sections: overview, accessing the reports, understanding the reports, report specifics, and using the reports.

Questions and Answers

       Question: How do I use QI/QM reports? (registered nurse, Arizona)
       Answer: The QI/QM reports are the major source of information to look at the more common occurrences in a skilled nursing facility (SNF). Surveyors can identify potential areas of concern. Also, the administration uses QI/QM reports to monitor quality assurance (QA). All information is taken from the MDS, so accuracy is of the utmost importance. These reports are used in conjunction with information that measures the strengths and weaknesses of a building.
       Question: Who is responsible for addressing the QI/QM reports for the facility? (licensed practical nurse, Michigan)
       Answer: Everyone. After team members code the information into the MDS, the management team is responsible for evaluating the information, first and foremost. Look at each item. Any items more than 75% or less than 25% merit special consideration. There is always room for improvement.
Any starred items (ie, items that are 90% or more above the state average) are areas of concern. First, evaluate if the data are correct; if not, correct them. Second, look at these areas and make decisions to improve the quality of care.
       The Director of Nursing (DON) is responsible for nursing care, which involves most of the 24 items, but the Director of Social Services and Activities, the dietitian, and even the administrator and medical director should also have input in the results. Due to the complexity of the QI/QM reports, many departments are part and parcel of the team, and everyone plays a part in the meeting of the goals to promote the residents’ highest potential level of functioning.
       Question: What triggers these items? (registered nurse, New York)
       Answer: There are 34 items, which come directly from the MDS, on this report. Perhaps your facility has a specialty and, therefore, some items will always be triggers. Either way, an explanation in QA is warranted so that it is discussed as a team. Different team members may be involved in different items.
       A facility should work well together to improve the quality of the care of residents by instituting new techniques and policies of caring for residents. The facility must show that problems are acknowledged and that management and staff are working toward improving care and meeting goals.
       Question: How often should I print the QI/QM reports? (registered nurse, California)
       Answer: It depends. The trend is to use a 6-month time frame, using the end of the month as an ending date. Surveyors use a 6-month time frame for their reference. However, the administrator or DON may request a 3-month or even 1-month timeframe to identify trends. Goals could be more easily updated with pertinent information with a shorter timeframe, and a 1-month or 3-month report might be more helpful for the post-acute residents whose lengths of stay are usually less than 3 months.
       Some say it takes a village to care for a child, and it takes a village to care for a long-term care resident. With so many caregivers and nursing personnel available, every facility needs to keep every individual resident healthy. The facility whose staff members work best together becomes the best one to live in. Getting ancillary departments that do not actually provide care involved with improving the well being of the resident helps the resident holistically.
       Question: We use standardized care plans. How do I make care plans more individualized? (registered nurse, Texas)
       Answer: It takes you back to nursing school, doesn’t it? There are several reference books out there that can help. Federal regulations state, “The care plan must be oriented toward preventing avoidable declines in functioning or functioning levels. There must be a realistic, directed effort to provide quality care in addressing immediate concerns and attempting to ensure that functional decline does not occur.” It should be an interdisciplinary effort. Problems related to appropriate diagnoses are stated, and behaviors listed, followed by goals and interventions. Care plans are dynamic and change as needed. A good care plan will show you the picture of the resident. And, yes, it takes a lot of work to keep it up to date.
       Question: I’m new at doing the MDS and RAP reports? What should include in the Resident Assessment Protocols (RAPs)? (licensed practical nurse, Florida)
       Answer: Think of RAPs as “the rest of the story.” They are a part of the Resident Assessment Instrument (RAI). The MDS is completed first, then the RAPs, then the care plans. As described in the MDS manual, RAPs are problem-oriented frameworks for additional assessments based on problem-identified items (ie, triggered conditions). The MDS manual states: “There are the main items for inclusion:
1. Nature of the condition
2. Complications and risk factors that affect the staff’s decision to proceed to care planning
3. Factors that must be considered in developing individualized care plan interventions; include appropriate documentation to justify the decision to care plan or not to care plan for the individual resident.
4. Need for referrals or further evaluation by appropriate professionals.”
       Furthermore, the manual states, “Documentation about the resident’s condition should support clinical decision making regarding whether or not to proceed with a care plan for a triggered condition and the type(s) of care plan interventions that are appropriate for a particular resident.”
The plan of care then addresses these factors with the goal of promoting the resident’s highest practicable level of functioning: improvement when possible or maintenance and prevention of avoidable declines.”
       There are 5 related decision-making processes. The MDS manual states:
1. The resident has a troubling condition that warrants intervention or if addressing this problem is a necessary condition for other functional problems to be successfully addressed
2. Improvement of the resident’s functioning in one or more areas is possible
3. Improvement is not likely, but the present level of functioning should be preserved as long as possible, with rates of decline managed over time
4. The resident is at risk of decline, and efforts should emphasize slowing or minimizing decline and avoiding functional complications (eg, contractures, pain)
5. The central issues of care revolve around symptom relief and other palliative measures during the last months of life.
       The Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) mandated that “facilities provide necessary care and services to help each resident attain or maintain the highest practicable well being. Facilities must ensure that residents improve when possible and do not deteriorate unless the resident’s clinical condition demonstrates that the decline was unavoidable.” Although this is very theoretical, the resident whose care is entrusted to us must be treated with respect and needed care.
       The formatting for RAP reports is determined by each facility and organization. Appropriate documentation must justify the decision on whether to devise an individualized care plan for the resident. It must be stated on the RAP summary sheets or in the RAPs themselves.
       Question: How do you actually do an MDS? (licensed practical nurse, Washington)
       Answer: We all have our own methods. I assess the resident and interview staff. I gather all my information and read everything from the medical record. In actually coding the MDS, I always start at the beginning of my assigned sections and work my way through the alphabet. I fill in everything I can and go back if there is a detail I missed on the first go round. To me, it’s just like reading a medication sheet—start at the top and proceed from there.
       Question: How do I keep track which Resource Utilization Groups (RUG) levels are ranked higher than others? It used to be so easy to figure it out. (registered nurse, Kentucky)
       Answer: We know that “RUX” is the most reimbursed RUG level. It includes extensive services (intravenous fluids in the last 7 days, intravenous medications, suctioning, tracheostomy care, or ventilator/respirator.) I have to refer to my chart of rankings of the RUG levels, because I am still learning the rankings. If anyone has an easy method of referring to them, let us know and we will publish it here.
       Happy charting!

Got a Question?

       If you have a question you would like to see addressed in a future “Mastering the MDS” article, contact Managing Editor Ryan Dougherty at ryand@hmpcommunications.com.