Portal de Periódicos da CAPES

Can Nursing Homes Use the MDS to Improve Quality?

1997; Wiley; Volume: 45; Issue: 8 Linguagem: Inglês

10.1111/j.1532-5415.1997.tb02977.x

1532-5415

John F. Schnelle,

Dementia and Cognitive Impairment Research

Journal of the American Geriatrics SocietyVolume 45, Issue 8 p. 1027-1028 Free Access Can Nursing Homes Use the MDS to Improve Quality? John F. Schnelle PhD, John F. Schnelle PhD Professor of Medicine, University of California, Los Angeles, Borun Center for Gerontological ResearchSearch for more papers by this author John F. Schnelle PhD, John F. Schnelle PhD Professor of Medicine, University of California, Los Angeles, Borun Center for Gerontological ResearchSearch for more papers by this author First published: 27 April 2015 https://doi.org/10.1111/j.1532-5415.1997.tb02977.xCitations: 21AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat The Minimum Data Set (MDS) provides a standardized approach to assessment that is useful for reasons ranging from resident care planning to research. It represents an important innovation for long-term care inasmuch as it creates the information base necessary to drive many important improvement activities. However, it is necessary to determine if the MDS system has had an impact on the broad array of process and outcome measures that are described in this issue of the Journal. Despite appropriate qualifying statements, the overall message is that the MDS has changed "important organizational characteristics," "process of care," and "outcomes." The authors, many of whom were involved in the development of the MDS, have reached a consensus that the MDS has significantly improved resident care. By making this argument they have set the occasion for useful debate. The findings presented in this series of papers should be evaluated in the context of three critical assumptions that must be made if outcomes and processes of care have, in fact, changed as a result of the MDS. These assumptions are: (1) Nursing home providers and health care professionals know how to change processes of care in a manner that affects outcomes; (2) Nursing home staff have the resources to implement effective care processes; (3) What is written in care plans and medical records is actually received by residents. Relevant to the first assumption, the articles point out that the specific processes that may have affected outcomes have not been identified. What should also be said, however, is that there is no strong evidence from any source to suggest what interventions may affect some of the outcomes in question. The lower rate of decline reported for cognitive functioning and ADL scores and the lower prevalence of dehydration illustrate this point. One must assume that nursing home staff have identified effective interventions, know how to target them to very frail residents with numerous comorbidities, and have done so without guidance from the clinical literature. This assumption places much pressure on providers who have not enjoyed an increase in resources that one might think necessary to achieve better outcomes. This issue of "resources" is the focus of the second assumption. If changes have occurred in care and outcomes, then nursing homes must already have had the resources to accomplish these changes and must be working more effectively under the influence of the MDS. This assumption is easier to believe for some of the data reported than for others. For example, the changes reported in this issue of the Journal and other places related to hospitalizations, catheters, psychotropic medicines, advanced directives, and physical restraints could be accomplished by changing the behavior of physicians and professional nurses. If these providers talk to families and residents differently on admission (restraints, advance directives) or simply stop writing orders (catheters, psychotropic medication, hospitalization), then these changes could be accomplished without the need for other direct care providers to work differently. However, changes in how orders are written do not necessarily translate into changes in how residents receive care. This was pointed out by the articles on advanced directives in a recent issue of the Journal.1-3 The assumption of "adequate resources" becomes more difficult to accept if one argues that the changes in what orders are written also reflect changes in the daily care provided to residents. For example, is there evidence that nursing staff changed how they provided incontinence care to residents whose catheters were removed? Did they reduce injury risk in residents released from restraints or implement behavioral management programs that made psychotropic medications less necessary? Did they have time to work more effectively in these areas, given resident-to-staff ratios that have not changed? If nursing homes do not have the resources to make important changes in the daily care residents receive and to use the MDS data in an effective manner, they are placed in a very difficult position by the survey process. The survey-based regulatory system evaluates nursing homes under the assumption that they do have resources to comply with ambitious OBRA regulations. For example, if a problem is triggered by the MDS, there should be care planning to reflect further assessment or a treatment strategy. If nursing home staff do not have resources necessary to actually implement these strategies, then the best staff can do is to emphasize paper compliance. The penalty for not describing appropriate levels of care in written materials is the dreaded survey deficiency. Paper compliance and how it translates into care is the focus of the third assumption. See also pp 977, 986, 994, 1002, 1011, 1017 The articles in this issue have made a major point that research nurses used a comprehensive approach to collect their data. They apparently reviewed charts, interviewed staff, family, and residents, and did direct observations. Unfortunately, no specific detail is provided as to how the interviews and observations were accomplished, and we are left to surmise about how much influence chart or written care plan data had in the final conclusions that were drawn. If charted data were the primary information source, then one must also accept the assumption that what was written in the charts is an accurate reflection of care processes and outcomes. We have reported evidence that care processes in two areas (toileting, restraint release) are reported to occur more consistently in charts than they are actually observed on direct observations.4 We have hypothesized that survey pressures in combination with inadequate resources and a strong desire to avoid sanctions explains these discrepancies. Furthermore, if providers are also placed under unrealistic pressures to not allow residents to decline, it is also plausible to hypothesize that they might react by being insensitive to at least smaller changes in resident behaviors that are relevant to some outcomes measured by the MDS. There is evidence to support the plausibility of this hypothesis. It has been reported that nurses aides overestimate food intake and that homes vary greatly in how the MDS incontinence severity ratings correlate with direct observations of incontinence severity.5, 6 In sum, the MDS has attempted to improve quality by providing better information to providers and by motivating use of this information with a regulatory system based on a "deficiency" mentality. The articles in this issue believe this strategy has been at least partially successful, and I also believe that some improvement has occurred. However, the degree of this success is very much open to debate, and paper compliance encouraged by the regulatory system may even be counter-productive to efforts to be innovative in changing resident care.4 Furthermore, new quality improvement efforts are being designed to compare nursing homes on MDS-derived indicators with the goal of identifying homes that implement processes better and that achieve better outcomes. Alternatively, homes that have poor outcomes will also be identified and, potentially, monitored more closely.7 This quality indicator strategy continues to be based on an acceptance of the three assumptions outlined herein. This strategy carries the risk that differences between homes on the indicators could reflect paper compliance and not reality. Alternative strategies to improve quality using MDS data, but not depending on the three assumptions outlined in this editorial, should be considered. Research centers could develop and implement interventions designed to improve the quality indicators generated by the MDS with two primary questions in mind: (1) How many and which residents respond when interventions are implemented under carefully controlled conditions? (2) How much does it cost to implement the interventions, and how do these costs match with current nursing home resources? Effective intervention processes with predictable outcomes could be operationally defined for dissemination to nursing homes and targeting criteria developed that would permit providers to direct the interventions to responsive residents only. Numerous potential findings could be produced by this research strategy, which would directly influence efforts at the policy level to improve nursing home quality. For example, it might be revealed that no intervention is effective in improving a quality indicator and that variability in outcomes is most influenced by factors that are beyond the nursing homes' control. There are many complex questions that must be addressed if the quality of nursing home care and its outcomes are to be changed. It is doubtful that many of these questions can be answered with a policy research strategy in which thousands of providers are given a method of assessment and monitored with the expectation that some will be able to use the information to produce better outcomes. It may, in fact, not be possible to significantly improve some outcomes in the very frail nursing home population. Alternative strategies that rely on controlled evaluations of specifically defined interventions designed to change MDS quality indicators as well as quality of life outcomes not measured by the MDS are needed. REFERENCES 1 Teno J, Lynn J, Wenger N et al. Advance directives for seriously ill hospitalized patients: Effectiveness with the patient self-determination act and the support intervention. J Am Geriatr Soc 1997; 45: 500– 507. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 2 Teno J, Licks S, Lynn J et al. Do advance directives provide instructions that direct care? J Am Geriatr Soc 1997; 45: 508– 512. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 3 Teno J, Lynn J, Connors AF et al. The illusion of end-of-life resource savings with advance directives. J Am Geriatr Soc 1997; 45: 513– 518. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 4 Schnelle JF, Ouslander JG, Cruise PA. Policy without technology: A barrier to improving nursing home care. Gerontologist, 1997, in press. CrossrefGoogle Scholar 5 Kayser-Jones J, Schell E, Porter C, Paul S. Reliability of percentage figures used to record the dietary intake of nursing home residents. Nurs Hom 1997; 5: 69– 76. Google Scholar 6 Crooks VC, Schnelle JF, McNees MP, Ouslander JG. Use of the Minimum Data Set (MDS) to rate incontinence severity. J Am Geriatr Soc 1995; 43: 1363– 1369. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 7 Zimmerman, DR, Karon SL, Arling G et al. The development and testing of nursing home quality indicators. Health Care Financ Rev 1995; 16: 107– 127. CASPubMedGoogle Scholar Citing Literature Volume45, Issue8August 1997Pages 1027-1028 ReferencesRelatedInformation