In December 1999, the Office of Geriatrics and Extended Care mandated use of the Resident Assessment Instrument and Minimum Data Set (RAI/MDS) for all long-term care residents in Veterans Affairs nursing home care units (VA NHCUs). The purpose of the RAI/MDS is to collect a wide range of resident-specific functional data from which a reasonable and comprehensive care plan can be formulated.
Another use for MDS data is categorization of residents into resource utilization groups version III (RUGS III) based on intensity of resource use. In private sector (non-VA) nursing homes, this functionality guides the prospective payment system (PPS). Assessments completed late (outside the mandated time frames) result in residents being dropped to the lowest RUGS III reimbursement category. Each instance can amount to thousands of dollars per month in lost revenue.
MDS data also can be used to calculate workload through assignment of a case mix index (CMI). Facility CMIs can augment staffing methodologies to establish the number and type of staff needed to care for a group of residents.
Finally, although not least in importance, the MDS data can be analyzed to gauge the quality of care in nursing homes. In non-VA nursing homes, MDS quality indicators (Table) are an integral part of the annual state survey process. In 2003, the Joint Commission on Accreditation of Healthcare Organizations QCAHO) announced the MDS quality indicators would replace ORYX measures for longterm care facilities accredited under JCAHO long-term care standards. This directly impacts VA NHCUs and underscores the importance of accurate MDS coding.
RESIDENT ASSESSMENT INSTRUMENT AND MINIMUM DATA SET (RAI/MDS) QUALITY INDICATORS
A literature review was conducted to identify existing RAI/MDS coordinator models and their relationship to nurse job satisfaction. Although little has been published, in non-VA nursing homes, the position of MDS coordinator is an established and valued professional role. Knapp (1999) stated:
Although some administrators believe that they can get by without assigning one person to the role of a CCC [clinical compliance coordinator], it is necessary to have this individual in place in order to coordinate the entire MDS process since it drives reimbursement... (p. 13)
MDS coordinators are primarily responsible for coordinating and submitting timely assessments in accord with the Omnibus Budget Reconciliation Act of 1987, which mandated comprehensive assessments to qualify for Medicare reimbursement, and Medicare PPS guidelines. These nurses are not usually expected to function as direct caregivers although they may have collateral roles related to quality assurance.
An early complaint about the RAI/MDS was the rapid development of an MDS coordinator model that took nurses away from the bedside. Marek, Rantz, Fagin, and Krejci (1996) commented:
While it is important to assure the MDS is completed properly and timely, one would hope that the primary goal of the instrument, to improve the quality of resident assessments and subsequent identification of problems which can be better managed, is the primary focus of the nurse coordinator's responsibility. However, it appears that MDS coordinators are "nursing" the regulations, not the residents. For nurses to positively affect resident outcomes they must be involved not only in assessing residents, but also in delivering care to residents, (p. 39)
Regarding nurse satisfaction, several studies (Agho, 1993; Biegen & Mueller, 1987; Cavanaugh, 1992) cite routinization as a key factor in job dissatisfaction. The Price-Mueller model defines routinization as the "degree to which jobs in an organization are repetitive" (Parsons, 1998, p. 19). The less a job becomes routine, the more it is perceived as satisfying. As a standardized instrument with explicit definitions, specific coding instructions, and inflexible completion time lines, the RAI/MDS process lends itself to routinization. To be assigned RAI/MDS completion responsibilities without reprieve could lead to nurse job dissatisfaction.
At the authors' facility, the previous model for completing the RAI/MDS was for all staff nurses (42 nurses throughout six diverse units) to function as a registered nurse assessment coordinator (RNAC) for every resident in his or her caseload. It was the RNACs responsibility to complete all RAI/MDS sections assigned to nursing as well as coordinate timely completion by other disciplines. Nurses' other responsibilities included direct resident care and charge nurse duties. Nurses rotated shifts and worked weekends and holidays.
While efforts were made to schedule time for RAI/MDS completion, it was an insurmountable task. The RAI/MDS is designed to assess a resident based on a specific 7-day time frame known as the observation period. Most of the MDS questions require an answer that considers the resident's functional status during the entire 7-day period, thus the MDS instrument is not to be coded until the observation period is complete.
Because of the limited window of time in which it is appropriate to code each RAI/MDS, it was nearly impossible to match 42 nurses' "documentation time" schedules to each of their resident's RAI/MDS schedule and weave this seamlessly into unit staffing patterns. It always seemed that when nurses were on duty and could be spared from direct resident care, the coding windows for their residents were not open.
This model for completing the RAI/MDS was inefficient, ineffective, and stressful for nurses and nurse managers. Quality indicator results revealed a better system needed to be developed, and the consequences for failing to do so would impact future financial stability, job security, and accreditation status.
One of the authors, who was nurse manager of the rehabilitative/restorative unit, had an idea for process improvement using a Paired RAI/MDS Specialist Model. One of the wards on her unit became the pilot ward for implementation of this new model.
The Paired RAI/MDS Specialist Model had four objectives. First, it was expected the RAI/MDS assessments on the pilot unit would meet all completion deadlines. A quality indicator (monitor) already in place was used to measure timeliness of completion. Monthly, all admission RAI/MDS assessments were audited for adherence to the completion time lines set forth by the Centers for Medicare and Medicaid Services (CMS). Similar to JCAHO standards for long-term care, CMS expects a comprehensive assessment to be completed for every resident by the 14th day after admission to a long-term care facility. Within 7 days of completing the comprehensive assessment, a comprehensive care plan must be developed by an interdisciplinary team. The authors' monthly rate of compliance is reported to the facility's Extended Care/Rehabilitation Restorative Care Service Line Council, and interdisciplinary corrective action plans are then developed to address deficiencies.
Second, it was believed the paired RAI/MDS specialists would become so proficient with the RAI/MDS that it would take them less time to code each assessment. To this end, a selfreport data collection tool was developed that allowed nurses to record the total amount of time required to complete assigned portions of the MDS, Resident Assessment Protocols (RAPs, which provide a link between raw data in the MDS and the resulting care plan), nursing portions of the interdisciplinary care plan, and reminders to the interdisciplinary team to complete their assigned parts of the RAI/MDS and care plan. Baseline data were collected for 3 months. During the baseline period, various nurses on the pilot unit completed the RAI/MDS for their caseload residents and recorded their time expenditures; using these data, an average RAI/MDS completion time was calculated.
Third, it was believed data quality (accuracy) would improve on the pilot unit through consistent use of the same "expert" nurse coders. An interrater reliability tool based on the 108 RUG III items within the MDS and specific CMS coding instructions was developed. Using this tool, 20% of new admissions to the NHCU were randomly audited each month. For each record in the sample, the interrater coded the tool according to medical record documentation that had been entered during the 7-day MDS observation period. Each completed interrater tool was then compared to the MDS that had been coded by one of the RAI/MDS specialists for that same observation period. Interrater agreement was calculated as a percentage of the number of items that were coded exactly the same by the interrater and the RAI/MDS specialist divided by the total number of items on the tool.
Figure. Comparison of timely completion of Resident Assessment Instrument and Minimum Data Set for the pilot ward and the rest of the Veterans Affairs nursing home care units (VA NHCU).
Fourth, it was believed there would be an increase in nurse satisfaction when most of the nurses were relieved of the dual responsibility for direct resident care and coordination of the RAI/MDS. A pre- and postpilot nurse satisfaction survey was developed and administered.
In June 2001, a 3 -month pilot was launched on one ward of the rehabilitative/restorative unit; the ward consisted of 21 JCAHO long-term care certified beds designated for restorative care. Average length of stay on this ward during the pilot study was 41.9 days, and average age of residents was 69.7 years. The most common primary diagnoses in the pilot population were above-knee amputation, late effects of cerebrovascular accident (CVA), arthritis, pneumonia, debility, hypertension, failure to thrive, and schizophrenia.
Responsibility for RAI/MDS coordination for all residents on the pilot ward was assigned to a team of two nurses. All other staff nurses were relieved of responsibility for completing the RAI/MDS.
The plan was to alternate two basic assignments each week to this nurse pair. The first assignment was responsibility for RAI/MDS completion and coordination for all residents on the ward. Four hours each day for 4 consecutive days (16 hours) was allotted to complete this assignment. The remaining time (24 hours) was to be spent in direct resident care. The second assignment was responsibility for direct resident care, rotation to off-shifts, weekends, and holidays according to unit guidelines, and assumption of charge nurse duties as needed (40 hours). One nurse had the first assignment for 1 week and the other nurse had the second assignment; thereafter assignments alternated weekly.
During baseline data collection, timely completion of the RAI/MDS on the pilot unit occurred 80% of the time as opposed to 63% of the time on the facility's other five units. During the 3-month intervention, timely completion increased to 100% on the pilot unit versus 93% for the other five units. Some improvement may be attributed to the Hawthorne effect, a phenomenon in which performance improves because attention is paid to people or to a process.
There was sustained improvement on the pilot unit (Figure). By adopting the new model, 100% timely completion was consistently achieved. By comparison, the cumulative rate of timely completion on the other units was 93.8% (range, 84% to 100%).
Unexpectedly, average time to complete each RAI/MDS increased by 10 minutes during the pilot (241 minutes at baseline versus 251 minutes during the pilot). However, this still compared favorably to the community benchmark of 278 minutes reported in a 2001 survey by the American Association of Nurse Assessment Coordinators (Oatway, 2001).
During the pilot, interrater agreement of MDS coding on the pilot unit averaged 94% compared to 89% for the rest of the units. While this difference may not have reached statistical significance, the authors believe the MDS data, MDS-based quality indicators, and RUG III reimbursement categorization have attained a higher degree of integrity. It should be noted MDS data validation was not performed before the pilot as the interrater tool had not yet been developed.
Because only 10% of the postpilot nurse satisfaction surveys were returned, nurse satisfaction could not be assessed. The nurse manager of the rehabilitative/restorative unit noted one reason for the poor return may have been that unit staff seldom gave her feedback when things were going well.
The model studied appears to be unique when compared to the model used in community nursing homes and to those used in other VA facilities. Alternating assignments prevented the RAI/MDS specialists from experiencing burnout, yet allowed them to develop a level of RAI/MDS expertise not possible in the previous case management model.
Before implementation of the . model, it had been assumed coordination of all RAI/MDS activity by the same two nurses would reduce the amount of time required to complete each assessment and care plan. With regular contact, it was believed these nurses would become experts with the nuances of the RAI/MDS instrument and the software, thereby improving efficiency.
In actuality, the new model served to illustrate how detrimental it is to have discontinuity when working with the RAI/MDS. For example, due to previously approved vacation time necessitating work schedule adjustments, one of the RAI/MDS specialists had a 5-week break from RAI/MDS coordination responsibility. Her average RAI/MDS and care plan completion time soared from 270 minutes to 398 minutes following this hiatus; this skewed the final average completion time. In contrast, average completion time for the partnering nurse dropped to 222 minutes during the pilot - nearly 20 minutes less than baseline.
Anecdotal comments from pilot unit nurses suggest a high level of satisfaction with the new model. The unit nurses have indicated they never want to return to the previous model in which all nurse case managers juggled both resident care and the RAI/MDS.
The two RAI/MDS specialists believed it was an asset to remain involved in resident care under the new model. When an occasional resident was "overcapped" into a bed on the opposite ward (resulting in less or no opportunity to deliver direct care to that resident), they found it much more difficult to complete the RAI/MDS and develop the care plan.
Using the Paired RAI/MDS Specialist Model on a pilot ward offered the opportunity to learn the following lessons prior to facilitywide implementation;
* Interdisciplinary team members paid more heed to the RAI/MDS nurse specialists. At baseline, individual case managers recorded instances of spending up to 30 minutes per RAI/MDS assessment communicating with interdisciplinary team members about completing their assigned portions. At the end of the pilot period, this time had been reduced to an average of 5 minutes per assessment.
* Discontinuity with the RAI/MDS should be avoided. As previously indicated, getting "out of practice" in using the instrument and the software intensifies the difficulty encountered in completing it. There is a certain "flow" that is achieved through regular contact with the RAI/MDS process.
* Itis beneficial to develop expert RNACs who also retain close ties to resident care. By having the RAI/MDS specialists continue their involvement with resident care and take their share of shift, weekend, and holiday rotation, animosity among staff was prevented.
* Rotating RAI/MDS coordination responsibility provides a respite from the RNAC role. This forestalls burnout and enhances opportunities to experience job satisfaction.
* For this model to be successful, units must be at or close to their full-time equivalent ceiling (i.e., the calculated quantity and staff mix necessary to deliver nursing care to a cohort of residents). Each unit will need at least two nurses who have excellent assessment skills as well as the ability to assimilate data into information, prioritize care needs, communicate with other disciplines, and develop measurable goals and reasonable interventions. These nurses also must be computer literate and favorably inclined toward the RAI/MDS process.
* Time assigned for RAI/MDS completion and coordination must be invioUte. For example, sick leave call-ins must be covered without compromise to the RNAC.
The benefits of using the model far outweighed any burdens encountered. Although there was a risk that the majority of nurses would lose knowledge of the RAI, the model made it possible to consistently meet CMS time frames. In addition, using paired nurse specialists enabled one nurse to cover for the absences of the other. The paired RAI specialists also were able to provide direct patient care, thereby retaining all of their clinical nursing expertise as well as expertise gained with the RAI process.
It also was easier and more efficient to educate fewer nurses about RAI changes (e.g., new software, upgrades, changes in CMS interpretation) and to follow up on implementation of changes. Likewise, there was less fragmentation of care; all of the other staff nurses were able to concentrate on care delivery and documentation of resident response. They were not burdened by the demands of a complicated, labor-intensive, time-bound, repetitive electronic process.
This model also did not require other nurses to pick up additional off-shifts, weekends, or holidays. Similarly, the RAI specialists did not lose any shift or holiday differential pay. Finally, implementing the model posed no cost to the institution.
Although the intent of the RAI/MDS was primarily to improve resident care, one criticism of the instrument is that it has resulted in nurses "nursing" the regulations instead of the resident. The Paired RAI/MDS Specialist Model allows nurses to continue nursing the resident and then use their hands-on assessment to accurately complete the RAI/MDS.
RAI/MDS data generate quality indicators that serve to paint a picture of the health care being delivered to residents in U.S. long-term care facilities. These data are available to regulatory agencies and health-care consumers. It is imperative that data coded into the RAI/MDS be accurate, and nurse assessment coordinators play a key role in this process.
Reimbursement hinges on accurate and timely completion of the instrument. A late assessment means lost dollars; therefore, facilities must implement systems that guarantee timely completion and submission of RAI/MDS data. By using the Paired RAI/MDS Specialist Model, 100% compliance with regulatory time frames was achieved.
The RAI/MDS Paired Specialist Model presents one way that findings from job satisfaction research can be used to creatively reengineer nursing duties and responsibilities. Benefits to nurses, residents, and organizations include enhanced satisfaction, improved clinical skill sets, increased efficiency, and a healthier bottom line.
The model described in this article is a workable compromise between having one designated RNAC for 50 to 100 residents (as done in the private sector) versus having all nurses assume RAI/MDS responsibility for residents in their caseload regardless of their skill set or familiarity with the RAI/MDS. The Paired RAI/MDS Specialist Model allows development of RAI/MDS expertise coupled with regular reprieves from the repetitive aspects of the RAI/MDS. Additionally, there is no loss of hands-on nursing skills as might otherwise occur when an RNAC is removed from direct resident care. This model is being introduced to the remaining five units at the authors' facility, with the expectation of achieving similar improvements in timeliness, accuracy, efficiency, and greater satisfaction with the RAI/MDS process.
- Agho, A.O. (1993). The moderating effects of dispositional affectivity on relationships between job characteristics and nurses' job satisfaction. Research in Nursing and Health, 16(6), 451-458.
- Biegen, M.A., & Mueller, CW. (1987). Nurses' job satisfaction: A longitudinal analysis. Research in Nursing and Health, /0(4), 227-237.
- Cavanaugh, SJ. (1992). Job satisfaction of nursing staff working in hospitals. journal of Advanced Nursing, 16, 1254-1260.
- Knapp, M. (1999). The role of the clinical compliance coordinator in long-term care. Balance, 3(6), 12-14.
- Marek, K.D., Rantz, M.J., Fagin, CM., & Krejci, J.W. (1996). OBRA '87: Has it resulted in positive change in nursing homes? Journal of Gerontological Nursing, 22(12), 32-40.
- Oatway, D. (2001, Fall). AANAC membership survey results - winter 2001. AANAC American Association of Nurse Assessment Coordinators, 4-6.
- Parsons, L.C (1998). Delegation skills and nurse job satisfaction. Nursing Economics, 16(1), 18-26.
RESIDENT ASSESSMENT INSTRUMENT AND MINIMUM DATA SET (RAI/MDS) QUALITY INDICATORS