Long-Term Care Survey Alert

5 steps to head off a survey or PR disaster.

The formula for managing your pressure ulcer quality measures calls for equal parts clinical and coding skills, a little statistics - and ample amounts of education and PR, as needed.

Sounds like a tall order, but these five steps should pull your scores down the red flagpole and/or explain scores over which you have no control.

1. Diagnose and code wounds properly on the MDS. Otherwise, you may code a wound as a pressure ulcer when pressure wasn't even a factor, cautions Christine Twombly, RNC, chief clinical consultant for Reingruber & Associates in St. Petersburg, FL. For example, if a skin tear is caused by injury (the resident fell and suffered a skin tear to his elbow) then you don't code that as a pressure-related skin tear or a pressure ulcer, Twombly advises. For more information, see "When To Suspect A Non-Pressure Ulcer," in the July 2002 Long-Term Care Survey Alert. Editor's Note: Access current and past issues by going to www.eliresearch.com and clicking on the OSS log in button at the top right. Enter your e-mail address and password (account number).

2. Identify and capture residents' "covariates" (risk adjustors) on the MDS. For example, covariates for the post-acute pressure ulcer measure include diagnoses of diabetes or peripheral vascular disease (I1a or I1j checked). Check out the covariates and exclusions for the pressure ulcer and other QMs at www.cms.hhs.gov/quality/nhqi/Snapshot.pdf.

3. Develop aggressive wound treatment protocols to eliminate as many stage 1 or 2 wounds as possible between the 5-day to 14-day assessment. That way, you can lower the percentage of post-acute residents whose pressure ulcers worsened or remained the same. "Providers tend to forget that many stage 1 and 2 ulcers can heal in a few days," says geriatrician David Gifford, MD, chief clinical officer for the Rhode Island quality improvement organization. Use an interdisciplinary focus that includes nursing, the physician, dietitian, pharmacist and a wound care consultant. (See the pressure ulcer reporting fax form for communicating with physicians.)

4. Build a data-driven defense for scores that reflect serious wounds you inherited from other settings. If your facility specializes in wound care, be prepared to show surveyors and consumers that you do admit large numbers of residents with pressure ulcers. "Compile data to show the actual healing rates for those wounds," suggests Gifford.

5. Tap the wealth of resources available through your state quality improvement organization. "Facilities and QIOs are working together in numerous ways to improve pressure ulcer prevention and care," says Laura Palmer, RN, project director for the nursing home quality initiative at the Colorado Foundation for Medical Care. "Facilities in every state have access to educational or sharing sessions, as well as a lot of clinical resource information and tools either through their QIO or on www.MedQIC.org," she notes.

Check This Out: There is also a national quality improvement collaboration around pressure ulcers in which most states are participating with their QIO by sending one or two facilities to join the collaborative learning sessions. "The QIOs and participating facilities then bring what is being learned on the national level back to their states to share best practices and new ideas," Palmer reports.

Some QIOs are hosting conference calls where facilities discuss case studies or share with each other what is working for pressure ulcer care. Experts sometimes provide clinical advice during the calls. The Colorado QIO also works with state surveyors to learn about common problems they are seeing with pressure ulcer care so the QIO can help providers address them. Surveyors report seeing shortfalls with "risk assessment, identifying skin breakdown, and with the consistency in the delivery of care," Palmer advises. Editor's Note: A complete list of the state QIOs and contact information is available at www.cfmc.org.