A

lmost every nursing facility in the United States has a computer that is utilized to complete and transmit the Minimum Data Set (MDS). However, most computers have many more additional software features that are not being utilized by the facilities but could provide money and time savings while increasing efficiency. Facility staff frequently complete processes manually that can be done more efficiently and quickly through use of their computer software.
       Think about this scenario. As a part of quality assurance, you are asked to conduct a review of weight losses and one sentinel event that flagged on the state QI profile report. You first contact the MDS coordinator to retrieve the QI report and are told that he or she does not know how to get the report or does not have access to that portion of the software program. So, after several attempts, you find the person that has access, and he or she prints the report, which takes just a few minutes. You manually make a list of the persons on which you would like to conduct a review and proceed to the nursing stations to review medical records that contain the information that you need.
       The first thing you start to investigate is the weights of the selected sample. You have decided to review 15 residents of the facility's total 132 resident population. You find out from the staff that all the weights are listed on the individual charts, and you retrieve all the charts and find the form on which the weights are listed. Since you are looking for significant weight loss based on federal guidelines, you calculate the percentages of weight losses over the past month, past three months, and past six months, provided all weights are documented on the record. If some weights are missing, you cannot get an accurate calculation, and you make note of this. If you identify there is a significant weight loss, you then review the care plan to see if the weight loss has been identified by the staff and placed on the care plan. You also review the completed MDS assessments within the time frames of the weight losses to see if they were correctly identified and coded on the MDS assessments.
       As mentioned earlier, the facility has a total of 132 beds and three nursing stations with 44 beds on each station. You have decided to conduct a review of five charts on each station representing only 11 percent of the total population. However, going to three different nursing stations, reviewing 15 medical records (sometimes forms are not filed in the same places on all stations), manually writing the information and calculating the weight-loss percentages, and making the other reviews takes you a minimum of three to five hours. You do this manually, because you have been told that there is no way to do this on a computer. When giving the analysis of the review to the administrator, you mention that it would be nice if a computer system could help retrieve some of this information. Someone in the room mentions that she remembers a function in her training that might do some of this, but it is never used.
       If the facility had been utilizing this function of their software, the scenario would appear like this: You go to the computer and pull up the weight report that contains all the weight losses according to federal guidelines for all residents in the facility (or just the 15 you selected); the software gives you the percentage of the losses, gives you the persons missing weights, etc. Time to do this: one minute. You then go the MDS application and review the MDS to see if the weight losses were reflected and, at the same time, check the care plan. For all 15 residents, the same review takes about 45 minutes using the computer versus the four to five hours to do it manually. In addition to the time savings, the information is more accurate, and you are able to also view timeliness of the assessments and care plans.
       With the investigation of the sentinel event, you discover that the MDS was improperly coded, causing the event to flag. Since this presents a significant concern to the facility and also requires investigation during a survey, you recommend the facility complete a correction MDS and submit it to the state. You mention to the administrator that if the facility had a method of checking the quality indicators prior to finalizing and submitting the MDS, they could have quickly caught the error and corrected it without having to submit and redo all the work again, a considerable time savings. You discover that the facility does have this functionality available, but the MDS coordinator does not utilize this function.

Why Are So Many Facilities not Taking Advantage of the Functionality Available to Them Through Their Software?
       Reasons for underutilization of software vary between facilities. Some possible contributing factors to this dilemma are:
       Resistance to change. Many employees have become accustomed to pen and pencil over the years and do not "trust" a machine to take the place of the manual functions. Also, especially in the clinical area, the average age of the licensed nursing employee is an age whereby computers were not introduced in their formal education and is sometimes a totally new experience for them. For many, just changing to a Windows environment becomes a real challenge; what seems so simple to some persons is difficult for others, such as learning how to use a mouse to maneuver in the Windows environment.
       Initial training and retraining of the software. When questioning employees regarding their training experience, most admitted they did not learn or understand all the possible functions well enough during their initial training of the product. Clinicians stated they were focused mainly on learning how to do the required necessary processes, such as completion and transmission of the MDS, and soon forgot all the other "nice" features available to them. Others felt that there was too much information at the initial training without follow through within an acceptable time frame. Others felt that they did not have enough "hands-on" experience with all the different functions the system was capable of performing. For many new employees hired since the software was installed, they virtually had no training other than what a fellow staff member had shown them.
       Prepurchase activity. Underutilization can be encouraged before the contract is signed to purchase the software. Often, the people who would benefit the most from the software and know what would help them to efficiently get their work done timely are not invited or included in the selection of the software. Sometimes this is obvious when one group in the facility chooses the software that other groups would be using. For example, it makes good sense for accountants to choose software for the billing department, but does it make sense for them to also choose the clinical software? Also, when cost is the main or only consideration in the purchase of the system, the systems can be underutilized as a result and end up costing the facility much more later in time, performance, and accuracy.
       Implementation. Employees admitted that there was not a well-planned or organized process for implementation of the system. Setups were not planned, hardware was not all working at the time of the training, or the employees did not start using the system until weeks after the training occurred. Often, they felt the wrong people were trained, and there was no method planned to train new employees as they were hired or started using the system. One of the main concerns was staff members were not told how the additional features of the system could help them with their required work processes or work flow. This is particularly evident with management, monitoring, and quality assurance activities. Appropriate implementation provides one of the best returns on investments that a facility can make. The old adage "pay now or pay later" really proves true in this area.
       Computer companies have become aware of some of these challenges and have instituted methods to provide better implementation and training to encourage success for the facilities. Industry professionals who have actually worked in nursing homes prior to joining a computer company should understand the needs and challenges facing the facilities and the industry. For those facilities desiring it, a full needs analysis should be done prior to implementation of a software package, whereby the consultant and the facility staff should identify the most important challenges for the facility. As a result, several options may be considered, such as having facility setups outsourced or completed prior to actual training; having training done in several sessions with time spaced to allow participants to use and become familiar with one application before learning a second one; and follow-up training or consultation planned several months after the initial training to assure participants understand and are using the system to best benefit them and their facility. Facilities taking advantage of a planned implementation process experience the best return on their investment.

Methods to Get Your Facility to Utilize and Benefit from Their Clinical Software
       Some methods to get your facility to utilize and benefit from their clinical software are as follows.
       1. Review all the reports or activities the staff are conducting and define those that are being done manually that could be done on the computer. Some examples of common functions done manually that may be done much more efficiently by your software are:
- Flow sheets
- Care plans
- Assignment sheets
- Facility assessments other than MDS
- HCFA reports
- Infection log reports
- Quality indicator reports
- Quality assurance queries (falls, weight losses, etc.)
- Skin reports
- Daily census reports
- Completed MDS and care plans
- RUGs case mix groups
- Assessments, transmissions, care plans, scheduling reports, etc.
- Revenue reports
- Complaints, suspected abuse, etc.
- Weight change reports.
       2. Determine how new employees are trained to use the computer. Is it considered an important part of their orientation?
       3. To get staff used to using the computer, require all reports that can be generated from the computer be done by this method.
       4. Investigate why staff are hesitant to use the computer (too much time to calculate, print, etc.) and determine if it is a "software" problem or a "person" problem.
       5. Determine if staff need more training and arrange through the vendor for more training or get a dependable qualified employee certified to train other employees.
       6. Make sure the staff members that could utilize the programs in the software have the proper access to the areas within the modules (i.e., can all nurses view the MDS?).
       7. Reassess location of computers. Are they located where necessary staff have convenient access?
       8. Assess the number of computers. Do you need more? Would you benefit from networking? If you need to network but do not have the expertise or equipment, you may want to consider off-site software hosting.
       Computers are viewed by many nursing home employees as "necessary evils." However, if utilized properly, as illustrated in the scenario presented earlier, computers can be one of the most valuable resources when it comes to managing and monitoring care and financial processes in a nursing facility. The industry is already experiencing regulatory monitoring via use of computers, and many facilities have this same advantage, that is, providing they are aware of and utilizing all their available software functions.