Health care organizations influence how work is performed by their clinical providers. During the past 20 years, evidence supporting this perspective has been acquired through studies conducted in health care settings, including nursing homes. Study foci have included the implementation of evidence-based practices, systematic implementation of changes in health care practices, and use of continuous quality improvement (CQI) as a specific change strategy (Grol, Wensing, & Eccles, 2003).
RNs play an essential role in the completion or coordination of the Resident Assessment Instrument/Minimum Data Set (RAI/MDS) process in nursing homes. The role of the MDS coordinator is defined in statute, as described in section 1819 (f) (6) (A-B) for Medicare and 1919 (f) (6) (A-B) for Medicaid in the Social Security Act as amended by the Omnibus Budget Reconciliation Act of 1987 (American Health Care Association [AHCA], 2005). How each RN performs the work associated with implementation of the RAI/MDS process and sustains its quality are likely influenced by the organization in which the RN practices.
The purpose of this article is to report findings of a qualitative descriptive study conducted with RN MDS coordinators. Study participants were asked to describe their work in its organizational context using Shortell, Bennett, and Byck’s (1998) CQI framework to categorize their descriptions. In a questionnaire, study participants were asked to rank the clinical data sources they used to complete the MDS instrument. This information-gathering process received special focus because it significantly contributes to the level of accuracy of MDS data, a long-standing concern among MDS data users (Teresi & Holmes, 1992; U.S. General Accounting Office [USGAO], 2001). Clinical implications of study findings are summarized.
The RAI/MDS used in nursing homes participating in Medicare and Medicaid nursing home programs is a state-of-the-art, computerized functional assessment instrument and clinical process providing data to clinicians, researchers, consumers, and policy makers (Mor, 2004). Although originally developed as an assessment instrument and process to guide the development of comprehensive care plans for nursing home residents, the RAI/MDS now serves multiple purposes. It functions as the data source for nursing home reimbursement, quality measurement, quality monitoring, and health services research, as well as interdisciplinary care planning (Mor, 2004).
The RAI/MDS consists of three components, including the MDS version 2.0 (Centers for Medicare & Medicaid Services [CMS], 2002/2006), associated Utilization Guidelines, and Resident Assessment Protocols (RAPs). Implementation of these three components may be thought of as the implementation of an evidence-based clinical guideline, given that the content of the MDS process is based on expert panel recommendations and clinical research (CMS, 2002/2006; Grol et al., 2003).
The MDS is a 450-item instrument, containing common definitions and coding categories. The Utilization Guidelines are a set of instructions about how and when to use the RAI, in essence describing the proper process or technical aspects of implementation of the instrument. After the MDS items are completed, as specified by the Utilization Guidelines, item responses may prompt or “trigger” the clinical assessor to further assess the targeted condition using RAPs. The 18 RAPS are a series of resources that summarize common clinical problems in nursing homes, as well as risk factors and assessment guidelines. RAPs are intended to help nursing home staff organize MDS information and seek additional information to aid in the development of individualized care plans useful to nursing home residents, nursing staff, and interdisciplinary team members (CMS, 2002/2006). Although empirical evidence of the efficacy of the care plan document is limited and actual implementation of the care plan is required for it to be of clinical value, the production of an interdisciplinary care plan document remains an essential component of the RAI/MDS process (Dellefield, 2006).
As a statutory requirement, the RAI/MDS must be conducted or coordinated by an RN who signs and certifies the completion of the MDS and RAPs. If the RN is completing the MDS, then his or her signature is also certifying the accuracy of the assessment. If the RN is coordinating the MDS process and other clinicians are completing specific sections, the RN’s signature certifies the completion of the MDS process alone (AHCA, 2005; CMS, 2002/2006).
The RAI/MDS was designed to be a routinely updated, dynamic assessment instrument (Morris et al., 1990, 1997). The original 1990 version of the instrument was revised in April 1995 and is in the process of being revised for a third time. The revision currently under development will incorporate more assessment items, including the domains of quality of life, pain, self-reported depression, palliative care, and a brief, performance-based cognitive assessment (Saliba & Maslow, 2005).
In this study, the implementation of the MDS was conceptualized as a systematic change in nursing home practice, with CQI as a useful strategy to sustain quality MDS implementation. The work of the RN MDS coordinator was conceptualized as involving the completion or coordination of the RAI/MDS, resulting in both a comprehensive and accurate interdisciplinary assessment and an interdisciplinary care plan document. The concepts of clinical implementation, CQI, and clinical work are briefly defined below.
Implementation of Systematic Change in Clinical Practice
Implementation is defined by Grol et al. (2003) as:
A planned process and systematic introduction of changes of proven value; the aim being that these are given a structural place in professional practice, in the functioning of organizations, or in the health care structure. (p. 10)
The three components of the MDS may be thought of as the national implementation process used by nursing homes participating in Medicare and Medicaid programs to standardize an interdisciplinary clinical assessment process to promote quality in nursing homes. Although the efficacy of the process of clinical assessment in nursing homes is widely accepted and is intuitively appealing, the value of a standardized assessment process is based on both the science and art of nursing home care (Kane, 1993).
Continuous Quality Improvement
CQI is a complex organization effort (Grol et al., 2003; Shortell et al., 1998). When applied to health care settings, CQI is used as an organizational strategy to sustain the quality of clinical processes over time. The notion of sustaining the quality of clinical processes over time is particularly relevant to the MDS process. Much of what this process entails is the collection and exchange of clinical information over extended periods of time, involving nursing and interdisciplinary staff with diverse educational preparations and clinical competencies.
In 1998, Shortell et al. wrote a seminal paper on the effects of CQI efforts on clinical practice. They systematically reviewed the literature between 1991 and 1997 in a wide range of health care journals, including those relevant to nursing homes. On the basis of this review, four interrelated organizational dimensions were posited as being necessary for the success of CQI efforts. Structural, technical (or process), cultural, and strategic dimensions need to be integrated organizationally to sustain CQI in any health care setting (Shortell et al., 1998).
Structural organizational dimensions refer to relatively stable characteristics of the system, providers, and consumers. Examples include staffin g levels, ownership, educational preparation of clinicians, and health status of consumers. Technical dimensions refer to processes, or how work is done, typically involving people, technology, or both. Cultural dimensions include organizational belief systems, professional claims, patterns of meaning, and work relationships among nursing and interdisciplinary staff. Strategic dimensions include “the plans and activities developed by an organization in pursuit of its goals and objectives, particularly in regard to positioning itself to meet external environmental demands relative to its competition” (Topping & Hernandez, 1991, p. 48).
The Clinical Work of the Rn Mds Coordinator
Awareness of the importance of organizational context on the clinical work of nurses, commonly referred to as the work environment, has increased during the past 5 years. For example, the 2004 Institute of Medicine report Keeping Patients Safe: Transforming the Work Environment of Nurses provided a summary of research evidence related to the effects of the nursing work environment on patient safety in both acute and long-term care settings.
Work is defined as continued activity directed to some purpose or end (Barnes, 1980). The majority of nurses, including those in nursing homes, work in health care facilities that are part of for-profit, not-for-profit, or governmental organizational entities. The purpose of the work of the RN MDS coordinator is to complete or coordinate the production of an interdisciplinary, comprehensive assessment based on accurate clinical data and an interdisciplinary care plan document. Typically, this work is performed in an organizational context of restricted resources, established routines, and external governmental regulation (Kane, 1990).
One study has focused on the role of the RN MDS coordinator. Piven et al. (2006) used a case study method to describe how the relationship patterns of MDS coordinators influenced nursing home care processes in two nursing homes. In one site, the MDS coordinators promoted good information flow and interpersonal connections. In the other site, neither of these were promoted by the MDS coordinators.
To place this single study in context, a large body of literature on the MDS does exist, although it is not focused on the role of MDS coordinators or their clinical work. The literature includes:
- Psychometric and efficacy studies of the RAI/MDS (Casten, Lawton, Parmelee, & Kleban, 1998; Fries et al., 1994; Fries, Hawes, et al., 1997; Hawes et al., 1995, 1997; Lawton et al., 1998; Mor et al., 1997; Phillips et al., 1997; Snowden et al., 1999).
- Use of MDS data in various clinical studies (Avidan et al., 2005; Crooks, Schnelle, Ouslander, & McNees, 1995; Culp, Mentes, & McConnell, 2001; Gambassi et al., 1998; Hendrix, Sakauye, Karabatsos, & Daigle, 2003; Mentes, Culp, Maas, & Rantz, 1999; Stevenson, Moore, & Sleeper, 2004).
- Descriptions of the development of clinical scales based on MDS data (Fries, Simon, Morris, Flodstrom, & Bookstein, 2001; Hartmaier et al., 1995; Hides, Frijters, & Teare, 2003; Morris et al., 1994; Mor et al., 1995; Williams, Li, Fries, & Warren, 1997).
- Studies of resource utilization groups (RUGs), the Medicare and Medicaid reimbursement system that is based on MDS data (Fries et al., 1994; Fries, Schroll, et al., 1997; Ikegami, Morris, & Fries, 1997; Hill & Yu, 2004; U.S. Department of Health and Human Services [USDHHS] Office of Inspector General [OIG], 2000).
- Governmental reports (USGAO, 2001; USDHHS OIG, 2000, 2001).
- Studies of the accuracy of quality indicators derived from MDS data (Bates-Jensen et al., 2003; Cadogan, Schnelle, Yamamoto-Mitani, Cabrera, & Simmons, 2004; Schnelle, Bates-Jensen, Levy-Storms, et al., 2004; Schnelle et al., 2003; Simmons et al., 2003, 2004).
- Literature reviews (Rantz, Popejoy, Zwygart-Stauffacher, Wipke-Tevis, & Grando, 1999; Rantz, Zwygart-Stauffacher, et al., 1999; Schnelle, Bates-Jensen, Chu, et al., 2004; Zimmerman, 2002).
This descriptive, qualitative pilot study included both focus groups and a questionnaire. The study purposes were to obtain descriptions of RN MDS coordinator work in its organizational context and to obtain preliminary data to use in the development of a more comprehensive questionnaire to measure RN MDS coordinators’ descriptions of their work. Focus group interviews were used because the method is well suited to the investigation of psychological and sociological processes associated with work (Morgan, 1988). The questionnaire was used to obtain descriptive data on sources of clinical data used to perform MDS-related work. Because workload is fundamental to quality of work, the questionnaire included an opportunity for study participants to self-report the amount of time required to complete different kinds of MDS assessments (Barnes, 1980).
The script used by the moderators was highly structured because the focus groups were used as a research method for a specific purpose (Morgan, 1988). This purpose was to acquire specific descriptions of the work of the RN MDS coordinator using Shortell et al.’s (1998) CQI framework to organize both the script and the data analysis. The definitions of structural, technical (or process), cultural, and strategic organizational dimensions of CQI used in the script were those used by Shortell et al. (1998).
Data were collected at the March 2006 American Association of Nurse Assessment Coordinators (AANAC) meeting held in Las Vegas, Nevada. Two months prior to the conference, the opportunity to participate in the focus groups was advertised on the organization’s Web site and in its quarterly newsletter. Conference participants responded in advance, either by telephone messages or by e-mail, to provide their availability to attend a 1-hour focus group. The conference sponsors restricted the scheduling of focus group sessions during any conference programs. At the convention site, informational handouts about the focus groups were prominently displayed as additional advertisements of the opportunity. Two private meeting rooms at the conference site were provided by the conference sponsors for the focus group sessions.
A total of 24 RN MDS coordinators of either an individual facility or a regional group of facilities volunteered to participate in the study. All were assured that participation was voluntary and that individual comments would not be disclosed to AANAC leadership or to their employers. The institutional review board at an affiliated university approved the recruitment, consent procedures, focus group script, demographic data sheet, and questionnaire.
Five focus groups, ranging in size from 3 to 7 participants, were conducted. Each focus group consisted of a 60-minute session, allowing time for the completion of the consent form, demographic data sheet, and questionnaire. Each session was audiotaped and was moderated by a licensed social worker or RN familiar with nursing home clinical practice. Participants received $20 at the end of each session.
The audiotapes of the five focus groups were transcribed. The transcripts were read independently by the principal investigator (M.E.D.) and a research assistant unfamiliar with nursing homes and the MDS. Shortell et al.’s (1998) definitions of structural, technical, cultural, and strategic organizational dimensions were reviewed. Transcript content was categorized using these four dimensions by both readers working independently. Any differences in how specific content was categorized were discussed and resolved using Shortell et al.’s definitions as the guide.
Demographic data of participants and facilities were summarized by calculating ranges and percentages. The selfreported minutes for completion of various kinds of MDS assessments were summarized by calculating ranges and averages. The data from the questionnaires were summarized using percentages. Bar graphs were created to display the ranking of each of the seven clinical data sources identified in the questionnaire. These sources included reading the clinical record, directly observing the resident, or talking with the resident, the resident’s family, direct care workers, interdisciplinary team members, and the physician.
Participants. A total of 24 RNs participated in the study. All were women (100%), of Filipino (4%) or Caucasian (96%) ethnicity, ranging in age from 34 to 62, with 60% older than age 50. Most had extensive experience in nursing: 75% had 21 years of nursing experience, and 25% had 1 to 20 years of experience. Most (92%) worked full time, and the remainder (8%) worked part time. Their education reflected the three kinds of RN preparation: a baccalaureate degree (42%), diploma (25%), and an associate degree (17%); 16% did not specify their kind of RN preparation. All (100%) participants were assisted with their work, such as by another RN MDS coordinator or a person providing data entry or secretarial assistance. Regarding their work as an RN MDS coordinator, 58% had 1 to 10 years of experience; the remainder had either 11 or more years of experience (38%) or did not provide information about their years of experience (4%).
Facilities. Study participants were employed in facilities located in 20 states. Types of facility ownership included for profit (34%), not for profit (46%), and governmental (12%), with 8% of facilities not categorized by ownership. Thirtyeight percent were part of a multichain system, 50% were not, and 12% were not identified by their affiliation with a nursing home chain. The size of individual facilities or facilities included in a region included 100 beds or more (25%), 100 to 299 beds (46%), 300 to 499 beds (4%), and 500 or more beds (4%), with 21% not described by bed size.
Shortell et al.’s (1998) definitions of structural, technical, cultural, and strategic organizational dimensions essential to successful CQI were used to organize focus group content within each of these four categories.
Structural Dimensions. Several structural dimensions affecting the work of the RN MDS coordinators were identified. A lack of adequate training about the MDS among MDS coordinators, other nursing staff, and members of the interdisciplinary team; turnover levels of all nursing staff, including the RN MDS coordinator; and a demanding workload were described as structural dimensions that adversely influenced their work. Most participants reported that they had other job responsibilities in addition to functioning as the RN MDS coordinator. The nature of their reporting relationships with either the director of nursing or the facility administrator influenced their work. Descriptions varied about the benefits of reporting to one or the other of these administrative staff.
Technical Dimensions. The technical organizational dimensions that were described included how clinical data were collected, the importance of charting systems to support the MDS assessment framework, and how coordination of the MDS process was demonstrated. Data sources for the MDS varied and were selected according to the dynamic workload of the RN MDS coordinator. Computerized charting systems that integrated MDS definitions into routine charting documents used by nursing staff were described as promoting assessment accuracy. Use of computer software that targeted activities of daily living (ADLs) charting elements that contributed to the RUGs reimbursement categories were popular. Charting systems that decreased the likelihood of “copycat” charting of ADLs by direct care workers and any clinical processes perceived to increase the accuracy of ADL charting were described as positively enhancing the work of the RN MDS coordinator. The coordination function of the RN MDS coordinator was described as providing oversight of the assessment process, particularly if interdisciplinary team members completed components of the MDS assessment. Gathering clinical information was also characterized as an act of coordination.
Cultural Dimensions. Two distinct cultural organizational dimensions were described. One was that of an organizational valuation of the RN MDS coordinator’s work as “paperwork,” and the other was that of an organizational valuation of the teamwork and clinical integration achieved through the work of the RN MDS coordinator. The majority of participants’ comments described organizational settings in which the MDS and the work of the RN MDS coordinator were not highly valued. For example, one participant described the use of threats as the only effective means of getting a response from management staff to better support the work of the RN MDS coordinator. Another described resident care as fragmented, with only the RN MDS coordinator having an integrated view of the resident and the care planning process. Other nursing staff were described as narrowly focusing on direct care activities and tasks, rather than on the critical thinking or cognitive aspects of nursing practice.
Strategic Dimensions. Presumably, all nursing home organizations have service quality and the production of accurate MDS assessment and care planning as their stated and/or actual goals. Organizational plans and activities, or strategies, vary in how they promote or impede the achievement of these goals. Several participants described their facility’s director of nursing and administrator as ill informed about the purpose and importance of the MDS framework and the work of the RN MDS coordinator. For example, one administrator explained to a coordinator that he did not need to know anything about the MDS because that was the responsibility of the RN MDS coordinator. Another participant described an administrator who told facility staff that they needed to fear the RN MDS coordinator because she was going to “come after them.” Perhaps this was said in jest, but it does not reflect a level of understanding about the RAI/MDS framework appropriate for a facility administrator. These descriptions suggest that few or ineffective activities were provided organizationally to promote competence in the director of nursing and administrator regarding the RAI/MDS framework.
In contrast, an alternate description of strategic support of the work of the RN MDS coordinator was provided by one participant. She described an organization that supported activities that fostered teamwork and communication. This support was described as essential to maintaining quality in the MDS process and facilitating the work of the RN MDS coordinator.
The use of accurate clinical data sources for the MDS process is necessary for achieving accuracy. However, uniform data collection sources and practices are neither mandated by statute nor precisely defined in the Utilization Guidelines (CMS, 2002/2006). The primary sources of clinical data were reading the clinical record (71%) and talking with the resident (72%). The least common data sources were talking with the physician (96%) and talking with the resident’s family members (60%). Talking with coworkers, including direct care workers (38%) and interdisciplinary team members (25%) were the second most frequently used sources of clinical information. These results are displayed in Figures 1 through 7.
Figure 1. Rank Ordering of Directly Observing the Resident as a Data Source for the MDS.
Figure 7. Rank Ordering of Talking with the Physician as a Data Source for the MDS.
The self-report of numbers of minutes required to complete various kinds of MDS assessments included a wide range. Time taken to complete a comprehensive assessment ranged from 60 to 360 minutes (mean = 170 minutes). Completion of a prospective payment assessment ranged from 20 to 210 minutes (mean = 84 minutes). Quarterly assessments required a range of 20 to 135 minutes (mean = 65 minutes), and assessments warranted by significant changes in clinical conditions ranged from 60 to 360 minutes (mean = 167 minutes). Both the comprehensive assessments and the assessments resulting from significant changes in clinical condition were the most time consuming to complete. Participants were not asked to distinguish between the times required to complete versus coordinate the completion of each kind of MDS assessment.
Several study factors limit the generalizability of the findings. The convenience sample was small. Study participants were perhaps more motivated about their work because of their conference attendance, compared with RN MDS coordinators who were neither AANAC members nor conference attendees. Self-reporting as a measurement of time required to complete various kinds of MDS assessments is not as accurate of a measurement of workload as a time study (Barnes, 1980).
Implications for Clinical Practice
The work of the RN MDS coordinator in its organizational context may be thought of as occurring on a continuum. One anchor is organizational contexts in which the structural, technical, cultural, and strategic organizational dimensions do not promote sustained quality implementation of the MDS process. For example, the organizational emphasis may be narrowly focused on regulatory compliance and a compartmentalized approach to MDS implementation. At the other anchor, the organizational emphasis may be on teamwork and an integrative approach to MDS implementation. Each RN MDS coordinator might assess where his or her organization fits on this continuum. Strengths and weaknesses of the organizational context related to sustained quality implementation of the MDS process can then be identified and addressed.
Dellefield (2007) described specific evidence-based strategies for improving sustained quality implementation of the MDS process that are consistent with these study findings and Shortell et al.’s (1998) CQI framework. For example, structural suggestions include a review of the RN MDS coordinator job description, the establishment of a standardized training program for new RN MDS coordinators, possible membership in AANAC, greater use of MDS-compatible language in all clinical documentation, and the development and implementation of a time study to establish a sustainable workload for the RN MDS coordinator.
Suggestions focused on technical (process) organizational dimensions include the establishment of uniform data collection practices and primary data sources for the MDS to be used within a facility; greater use of electronic charting, particularly systems that enable direct care providers to document in real time and avoid “copycat” charting of preceding entries; and use of an internal auditing system for MDS data accuracy.
The quality of RN MDS coordinator communication and interpersonal relationships may advance facility-level efforts focused on culture change. Promoting respect, empowerment, and positive work relationships among direct care providers is possible when the RN MDS coordinator gathers clinical data by direct communication with nursing home staff members. These concepts are consistent with the goals of efforts focused on cultural transformation of nursing homes (Weiner & Ronch, 2003).
Nearly all nursing homes communicate to both consumers and staff that quality health care is their primary goal. The strategies used to pursue this goal vary and reveal the actual plans and activities undertaken to achieve quality. Determining the strategic role that MDS implementation plays in each organization is useful for an RN MDS coordinator. It may be determined by learning what facility staff at all levels of the organization understand about the MDS process and identifying the amount and kinds of resources allocated to MDS-related work. These activities will provide insight into the kind of education about the MDS process that the RN MDS coordinator may provide for all facility staff. Teaching members of the organization about the fundamental and potentially integrative role that the MDS process contributes to facility quality is one educational approach.
It is unlikely that all suggestions provided under each dimension of Shortell et al.’s (1998) framework are feasible to implement in any organization. However, in even the most difficult of organizational contexts, at least one positive change can be made to improve the organizational context in which the RN MDS coordinator works.
Further study of the work of the RN MDS coordinator in its organizational context is needed, given the state of the literature on this topic and the important and diverse uses of MDS data. RNs are in an excellent position to advance this effort because they are actually working as RN MDS coordinators and have specific knowledge of MDS-related work activities. Most important, they directly experience how the organizational context influences their work. Interest in acquiring greater understanding of the work of the RN MDS coordinator in its organizational context also extends beyond the discipline of nursing. Because the accurate interdisciplinary comprehensive assessment and care plan document are believed to influence nursing home quality, this topic is important to all nursing home stakeholders who care about improving the quality of nursing home care (Arling, Kane, Lewis, & Mueller, 2005; Mor, 2004).
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Figure 2. Rank Ordering of Reading the Clinical Record as a Data Source for the MDS.
Figure 3. Rank Ordering of Talking with Direct Care Workers as a Data Source for the MDS.
Figure 4. Rank Ordering of Talking with Resident as a Data Source for the MDS.
Figure 5. Rank Ordering of Talking with the Resident’s Family as a Data Source for the MDS.
Figure 6. Rank Ordering of Talking with Interdisciplinary Team Members as a Data Source for the MDS.