Refocusing the nursing staff for PPS success - Medicare Prospective Payment System - Cover Story

Nursing Homes, May, 1998 by Judy Smith

This project scrutinized and improved nursing processes and documentation

While the details of a Medicare Prospective Payment System (PPS) are being developed, many workshops are being held to speculate on how it will be implemented at the facility level. These workshops are basing information on what has been done in the RUGs III demonstration project. Unfortunately, what has been done varies from one demonstration state to the other, from one intermediary to the other and, in some instances, does not coincide with the written regulations for the demonstration project. What's more, caregivers in some facilities are so focused on or distracted by the mandate for automation that the question could legitimately be asked, "Where is the patient in all this?"

Meanwhile, the literature reporting positive outcomes relating to nursing care is scant. Indeed, documentation scrutinized for the past four years by the author and cohorts in many facilities across the country revealed positive outcomes in nursing documentation to be almost nonexistent. The questions arise: "Were positive outcomes achieved and not documented?" or "Were positive outcomes not being achieved (and, if not, why not)?" This leads to the big question: How will the distractions of increased numbers of MDSs to complete and transmit to states, computerization, and confusion about new documentation for reimbursement affect nursing care delivery and the achievement of positive outcomes?

Caregivers and providers seem distracted specifically by such issues as "Which MDS categories are weighted for the best reimbursement rate?" and "Who should actually do the MDS?" Many questions seem to focus on computer software problems. While these are important issues in need of resolution, the more important question to be resolved may be "How can nursing care be delivered more effectively without increasing staffing, while documentation accurately captures information necessary for appropriate reimbursement?"

While this article does not intend to imply that increasing nursing staffing is the answer (it probably is not), the following numbers should encourage providers to look very closely at how nursing time was and is spent. For example, the facility that staffs with four nursing hours/patient/day really offers approximately only 13 minutes of RN/LPN time per patient shift, once one has subtracted 2/3 of the time for CNA time and 50% of RN/LPN time for administration of medications. The remaining 13 minutes is available for nursing management of actual and potentially unstable conditions through assessment, physician consultation and implementation of new orders. Additionally, time is spent doing treatments, supervising nursing aides, counseling families, documenting, doing MDSs and care plans, etc., etc. And how much time is wasted by nurses answering the phone, emptying wastebaskets, completing redundant forms, doing housekeeping and performing dietary tasks? This, too, is worth exploring.

Begin the exploration with this question: Is the nurse the appropriate person to be doing the data input, or should the scant amount of nursing time available be focused on more accurate and extensive patient assessment so that subtle changes can be identified and proper action taken? When these data are clearly documented in the medical record, could not a well-trained clerical person retrieve the data needed for the MDS completion, with a nurse doing the final review before transmission?

As mentioned earlier, based on the published literature available, the relationship between nursing care and positive outcomes has not been clearly illustrated. Additionally, there is little in the published literature to describe the methods, processes and systems of nursing care delivery that achieve more positive outcomes.

According to Smith (see "Suggested Reading"), positive patient outcomes related to nursing care were increased more than 700% (from 8% to 63%) in one facility within one year by revising and refocusing the nursing role. In this project, nursing staff was not increased to achieve these results. The four major phases in this role-revision program were:

1. Freeing up nursing time by task shifting. This involved exploring how nurses spent their time during an eight-hour shift, focusing specifically on clerical, housekeeping and laundry functions.

2. Refocusing time on the nursing process - i.e., assessment, problem identification, care plan development, care plan implementation and ongoing revision of the plan to get results. This involved showing nurses how to do an in-depth assessment, approximately identify problems and develop a useable care plan (useable especially in day-today care and outcomes measurement). Job specifications were rewritten and performance evaluations refocused, as well.

3. Providing education/training in critical thinking to encourage focusing on outcomes, as opposed to simply passing medications and going through basic nursing task completion.

4. Assigning accountability to individual nurses, specifically, a patient case load for which the nurse is accountable for timely assessments and MDS completion. The nurse is responsible for the case load over the long term.