MDS Alert

But is it a clinical issue, MDS coding - or neither

They say not to believe everything you hear or read, which is good advice for viewing quality measures and indicators that surveyors or consumers might use to jump to false conclusions about your facility.
 
So before your facility over- reacts to a QI or QM report, figure out what's really going on so you can identify the appropriate action. To address an outlier score, providers have three options ... and doing nothing is not among them, says Steven Littlehale, chief clinical officer for LTCQ Inc. in Lexington, MA. The choices include:

 1. Design a quality improvement plan to better the outcome area;
 2.  Design a quality improvement plan to better the accuracy of MDS assessment; or
 3.  Design a public relations plan to counter potential allegations of poor care by surveyors, consumers or malpractice attorneys.

Ask this Simple Question
 
To figure out which of the three options is the right path, examine each outlier score and ask yourself: "Is this what I expected to see?" Littlehale notes that clinicians usually have excellent "hunches" as to where the quality improvement opportunities lie in a facility, so the answer should usually be "yes." The surprise scores are the ones you want to look at carefully, as they may have slipped through the QA cracks. Or the unexpected scores may be more related to another issue, such as MDS accuracy, Littlehale notes.
 
In other words, always analyze the reason for the data and don't take anything at face value, agrees Jacqueline Vance, director of clinical affairs for the American Medical Directors Association. "Your facility may be in the 95th percentile for pressure ulcers because you specialize in wound care and are accepting many patients with pressure ulcers," she notes. Yet the facility may actually be providing better care for pressure ulcers than the facility whose scores rank in the 20th percentile for pressure ulcers.

Work the Problem Backwards
 
But you can't just eyeball the scores and your admission profile or other factors in deciding how to proceed.
 
Say your QI for falls is high, for example. "The interdisciplinary team should already know they've had a certain number of falls and which residents have had the incidents," says Darla Watson, a nurse and vice president of beneficiary support with Mariner Healthcare in Atlanta. "But if the high QI for falls occurs out of the blue where staff are wondering what's going on, the team needs to consider a data entry error or figure out if an immediate action plan should be put in place."
 
If the numbers appear accurate, the staff could get to the "root cause" of the falls by identifying and analyzing who fell, when, where and why. "It might be that most of the falls occur during change of shift time when staff aren't available," Watson suggests. "Or perhaps a single caregiver may need more training on transfer techniques."
 
Or sometimes you'll find that the residents have a perfect care plan in place but staff haven't been following through, Littlehale notes.
 
A sudden spike or dip in a QI or QM usually signals an MDS coding issue. "The sudden changes may indicate someone attended a class and learned to assess/code differently (correctly or incorrectly)," Littlehale says. But sometimes spikes can also reflect a clinical issue, such as an outbreak of flu or respiratory infection. "In that case, the facility might want to look at its flu and pneumonia immunization rates to see if that might have prevented the outbreak or related complications," Littlehale suggests. You'd also want to review how the staff responded to the infection outbreak and take a look at infection control procedures.

Is It the FAP's Fault?
 
In some cases, your investigation will show that the score itself is skewed. For example, if your facility admits lots of patients with serious wounds, the quality measures' facility-adjusted profile (FAP) may not be enough to do the trick. Littlehale worked with one atypical subacute nursing facility with high FAP-adjusted pressure ulcer scores on the QM reports. "We backed out the residents admitted with pressure ulcers and those who went to the hospital and returned with a pressure ulcer created in that setting," he says.
 
It turns out the facility actually had a below average number of pressure ulcers, even though it specialized in wound care patients. As a result, the facility determined it had a public relations issue on its hands, rather than a clinical or MDS issue.
  
The same thing can happen to facilities that admit residents with other long-term conditions, such as behavioral symptoms or a stage 3 or 4 pressure ulcer. "These pre-existing conditions are often still present on the first MDS assessment that counts for the post acute and even chronic care measures," Littlehale cautions. "Also, even though you don't count your admission assessment, the significant change or significant correction assessment will count in the profile and trigger the QM or QI."

Don't Stop Short
 
Don't make the mistake of simply blaming your admissions profile for the facility's high score on a QM/QI, however. For example, if the facility admits a lot of wound care patients and has the QI/QM scores to show it, the next question is: Are you healing ulcers at an acceptable rate? LTCQ has a product, for example, that can compare healing rates of residents' pressure ulcers (risk adjusted) to national norms. "But a facility could do a qualitative assessment on its own by having a wound care expert take a look at each resident to determine if the pressure ulcer is progressing as one would expect, given the person's health condition," Littlehale suggests. Questions to ask include: