In nursing homes, quality measures (QMs) serve as key indicators of resident outcomes and care effectiveness. Derived primarily from Minimum Data Set (MDS) assessments and Medicare claims, these measures influence public reporting on the Centers for Medicare & Medicaid Services Nursing Home Care Compare website, impact the Five-Star Quality Rating System, and help identify areas for improvement. Effective management of QMs involves more than one department. This article delineates the importance of each interdisciplinary team (IDT) member for quality improvement and details the coordination needed across the team, including nursing, therapy, dietary, and social services. 

QMs fall into two categories: short stay (for residents with stays of 100 days or less) and long stay (for residents with stays 101 days or longer). Each measure is based on specific MDS items with a defined target period, and it may have exclusions or risk-adjusting covariates. Accuracy in MDS coding is critical. Even small errors can have significant consequences on QM outcomes and publicly reported measures. For example, inaccurate reporting on the staging of pressure ulcers or functional status can misrepresent actual care quality and lead to adverse resident outcomes and survey citations. It can also have a negative impact on the public’s perception of the facility.

Nurse Assessment Coordinators 

The nurse assessment coordinator ensures the MDS is completed accurately and on schedule but relies on timely documentation from the rest of the team. For instance, sections GG, J, K, M, and N require current and accurate data on resident functioning, clinical status, skin condition, and medications. If information is incomplete or delayed, the assessment may misrepresent the resident’s condition and skew QM results. An accurate MDS depends heavily on clear communication and thorough documentation from nursing, dietary, social services, therapy, and other departments.

Direct Care Staff and Therapists

Direct care nurses are often the first to detect changes that impact QMs, such as skin breakdown, functional decline, new infections, or unplanned weight loss. Their observations must be reported and documented promptly to support accurate MDS coding and care planning. For instance, the long-stay QM for Percent of Residents with Pressure Ulcers depends on the correct assessment and documentation of skin status throughout the resident’s stay. If skin assessments are incomplete or do not accurately identify the etiology of the wound, the MDS may be coded incorrectly, increasing the facility’s reported rate of pressure ulcers, regardless of the actual quality of care delivered.

Both direct care staff and rehabilitation therapists play a critical role, particularly in QMs related to function and mobility. Short-stay measures, like the Discharge Function Score, and long-stay measures, such as the Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased, use data from section GG. The episode documentation for the various GG tasks from direct care staff and the evaluation and treatment notes from therapists help determine usual performance for MDS coding, not the best or worst of how the resident was able to perform. If therapy documentation and direct care staff reports do not match, this inconsistency may lead to inaccurate MDS coding. The facility’s team of qualified clinicians must be able to analyze this data to appropriately determine and document the usual function and thus support MDS coding. 

Dietary Services

Documentation of dietary services also contributes directly to QMs tied to nutrition and weight loss (e.g., monitoring and measurement of height and changes in weight over time). To ensure accuracy in weight collection, the team must have a process to weigh each resident: at the same time of day; with residents wearing similar clothing; with residents in a wheelchair or not; foot pedals on or off if in a wheelchair. Dietary staff and dietitians must work closely with nursing staff to monitor intake, intervene early when weight changes occur, and ensure that appropriate nutrition plans are documented and implemented. Poor coordination in this area can lead to avoidable weight loss or delays in intervention that affect both resident outcomes and QM performance.

Social Services

The social services staff has an impact on measures related to psychosocial well-being, behaviors, and medication use. QMs concerning antipsychotic medications, for example, are linked to the behavioral symptoms documented in section E. Social services staff are highly involved in behavioral assessments, care plan interventions, and discussions with residents and their families. They can help ensure that medications are used only when necessary and nonpharmacologic approaches are explored and documented. This documentation is not only good clinical practice, but it also directly affects QM outcomes and survey citations.

Managing QMs in Quality Assurance and Performance Improvement

To manage QMs effectively, the IDT must incorporate routine data analysis and performance monitoring into the quality-assurance and performance-improvement processes. The MDS 3.0 QM User’s Manual v17.0 outlines how each measure is calculated and covers specific MDS items, look-back periods, risk adjustments, and exclusions. Understanding these details is essential as the first step to identifying quality improvement and ensuring MDS accuracy. 

The second step for quality improvement is to identify the root cause of why a QM is trending in the wrong direction, such as an increase in pressure ulcers or a spike in antipsychotic use. Examples of root-cause analysis (RCA) are reviewing care delivery systems, staff documentation habits, communication breakdowns, or gaps in education. Direct input from staff closest to the resident and, when appropriate, the resident or family can be helpful. A well-conducted RCA helps distinguish whether the issue is related to actual care concerns or to documentation, assessment, or coding practices. Only by understanding the reason behind a QM issue can the team develop meaningful corrective actions and prevent recurrence.

Interdisciplinary Communication

Communication among the IDT members must be routine, structured, and data informed. The team should regularly confer about residents who are triggering and/or are at risk of triggering. For example, if a resident has had multiple falls or is experiencing functional decline, the team should review current interventions and assess whether care plans are effective. These discussions should include documentation monitoring, MDS accuracy checks, and input from all relevant disciplines. This level of collaboration helps ensure that the entire team understands the value of accurate documentation that will be reflected on the MDS, along with the team’s role in improving QM accuracy.

Summary

Successful QM management ultimately requires a shared commitment to data accuracy, timely communication, and coordinated care. Each IDT member has a defined role, but no single role is sufficient on its own. By taking a team-based approach, nursing homes can better manage their QMs, meet regulatory expectations, and—most importantly—improve outcomes for the residents they serve.

Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, is senior curriculum development specialist at the American Association of Post-Acute Care Nursing (AAPACN).

The American Association of Post-Acute Care Nursing (AAPACN) represents more than 17,000 long-term and post-acute nurses and professionals working in more than 5,750 facilities through its subsidiary associations, the American Association of Nurse Assessment Coordination (AANAC) and the American Association of Directors of Nursing Services (AADNS). Learn more at AAPACN.org.