What is your Staffing Data Saying About Your Quality?

LeadingAge Kansas Members Ace PBJ Staffing Out of the Gate. What is your Staffing Data Saying About Your Quality?

CMS used Payroll Based Journal (PBJ) data for the first time in the Five Star Quality Rating
System for the April reporting quarter to calculate the staffing domain star rating. The staffing domain rating is important because it influences the overall star rating. It can add an overall star by rating four or five stars and greater than the health inspection rating or it can subtract an overall star by rating a one star. CMS intends to use this data to inform the survey process to help identify if a provider’s staffing is an underlying root cause for quality issues. One of the requirements of a successful Quality Assurance Process Improvement (QAPI) program is performing Root Cause Analysis (RCA). RCA is a structured process used to identify root causes of an event that resulted in an undesired outcome. Will CMS identify staffing to be the root cause of quality issues? In other words, are the staffing numbers, ratios and competency leading to poor outcomes?

In the graph below, LeadingAge Kansas members staffing performance is compared to both National Non-Profit (orange bar) and Kansas Non-Profit (medium blue bar)peer groups. The vertical axis is the star rating and the horizontal axis are the groups including: National NP, Kansas NP, and the seven regions in Kansas that make up LeadingAge Kansas
membership.

Six out of the seven regions or 85 percent have staffing star ratings higher than both state and national bench marks. All seven regions or 100 percent are above 3 stars which is the bench mark set by CMS to participate in incentive programs that waive a beneficiary’s 3-day hospital stay requirement thus making provider more attractive in the pay for quality not quantity environment.

Providers in the post-acute care realm know the importance of providing quality care and
attaining staffing longevity and mastery. Quality forms the basis of a provider’s reputation in the region it serves. A successful reputation will ensure business sustainability through
attracting and keeping talented staff and achieve occupancy rates that reflect the maximum number and most desirable referrals.

CMS’ next hurdle set in place for the July reporting quarter focuses on RN staffing. Specifically, the requirement that there be an RN present at least 8 consecutive hours per day, 7 days per week. Now that providers submit staffing data it is easy for CMS to verify compliance with this metric. About 6% of providers in the nation’s PBJ data shows an absence of an RN 7 or more days in a quarter and those days occur mostly on weekends. Providers that report 7 or more days without an RN will receive a one star for staffing for a quarter despite the presence of a waiver of this requirement. Providers that rate one star in staffing will drop their overall rating by one star.

There are many steps that can be taken to ensure your data is the most accurate.

PBJ data

1. Ensure the right people are involved with the staffing data
2. Ensure the data is submitted timely. PBJ submissions are due by day 45 after the reporting
   quarter
3. Verify accuracy of PBJ data through Certification and Survey Provider Enhanced Reports
   (CASPER)

Minimum Data Set (MDS)

1. Verify accuracy, completion of all required MDS’ and ensure timely submission
2. Resident level documentation follows accepted standards and supports information on the MDS
3. Orientation, ongoing education and competency of staff regarding the quality measures and which MDS items are used in their calculation

Initiate programs to improve quality

1. QAPI (Quality Assurance/Process Improvement)
   INTERACT (Interventions to Reduce Acute Care Transfers) http://www.pathway-interact.com/
2. Restorative Nursing and Nurse’s Aide Clinical Ladder Program
3. CDC – STEADI (Centers for Disease Control – Stopping Elderly Accidents Deaths and Injuries) tool kit for Falls https://www.cdc.gov/steadi/index.html
4. Infection Control, Antibiotic Stewardship Program
5. Dementia Training, orientation, and ongoing education and competency
6. National Partnership to Improve Dementia Care in Nursing Homes
7. Competency tied to pay for performance
8. Certificate programs tied to clinical ladder programs

Author: Susan Chenail RN, CCM, RAC-CT, Senior Quality Improvement Analyst, LeadingAge NewYork