Chain of Command

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olid lines, dotted lines, and horizontal lines are all part of organizational charts and indicate the different report structures within the facility. Where do we fit in? Are we supervisors or line staff? What is your main role? Do you report to the Director of Nursing (DON) or the administrator? Are you also a DON or Assistant Director of Nursing (ADON)?
       Solid lines, of course, indicate an immediate direct supervisor, while dotted lines indicate an indirect supervisor. Some have indirect reporting lines to a consultant. And below the lines, there may be line staff who report to the Minimum Data Set (MDS) coordinator.
       Let us say your job title is MDS coordinator or Resident Assessment Coordinator (RAC). MDS coordinators are usually in a full-time position without being an ADON or DON. Examine the organizational chart. Is your direct supervisor the administrator who is responsible for overall operations, budgets, revenue, and costs? Or are you under nursing because you are a nurse? Every organization is different, but the MDS coordinator is traditionally placed in the nursing department to report to the DON. Due to the reimbursement impact of the MDS, however, many MDS coordinators now report to the administrator.
       So, what authority do you have? Coordinators are in charge of making sure the interdisciplinary team completes its sections in a timely manner to ensure compliance with current Omnibus Budget Reconciliation Act (OBRA) and Medicare MDS regulations. What is your responsibility to the facility about incomplete documentation by licensed staff and nursing assistants?
       You are probably somewhat responsible for documentation and education. Most of us are in a position to let the staff know about deficiencies. Most MDS coordinators are given some responsibility to supervise staff for proper documentation.
       The approach you take with your peers when there is a mistake or deficiency will ultimately be reflected in the response you receive as well as the overall functioning of the facility. Be aggressive and you will probably get nowhere. Be exasperated and you will also probably get nowhere. Small-group discussions about the expectation for documentation might be the most useful way to educate nurses, and one-on-one teaching has also been effective in showing others that a problem exists.
       MDS coordinators are sometimes frustrated by the lack of quality, solid documentation available to ensure accurate coding of the MDS. You know what documentation is useful and demonstrates good nursing care as well as the type of documentation needed to optimize revenue. If nurses document everything that is pertinent to the resident, everyone who reads the chart will have excellent communication and, of course, justify a higher reimbursement through Resource Utilization Groups (RUG) levels. The expectation is for the nurse to chart information related to the admitting diagnoses, a partial systems exam, tolerance to treatments, pain and pain medication effectiveness, and basic care of the resident. Additionally, MDS coordinators look at medication administration records, treatment administration records, and nursing assistant documentation. MDS coordinators are frequently coaching others. One approach to improving documentation is to educate the interdisciplinary team on the types of clinical information asked on the MDS and how its documentation can impact the coding of the different MDS items.
       The question is, do you report deficiencies to an administrator or DON? Most department heads report to the administrator, so that is usually the person to whom you report deficiencies. The medical records person will also audit charts and provide the appropriate department a list of deficiencies.
       Presenting information to the quality assurance (QA) committee acknowledges that a problem exists, and it will list solutions for correcting the problem. This may be a team problem and solution, but it definitely must be reported.
       Personalities have a lot to do with your happiness in your lot in life at work. What are the personalities of the administrator and DON? How about yours? All upper management persons have good traits and bad. The trick is being able to adjust your attitude to suit the needs of the facility and work for the good of the company.
       Let us examine the other employees you work with in the nursing department. If you are a supervisor, you have the authority to direct others in their daily job responsibilities. How you phrase your directions or suggestions means a lot to the nursing staff. You get a lot more cooperation with honey than vinegar. You can be a great leader with strong but kind direction, instead of a strong, intimidating direction. While both command respect, the staff will appreciate your knowledge and concern for their performance.
       Regarding the attitudes of the employees who actually work in the clinical setting, the author Ian I. Mitroff, in Why Some Companies Emerge Stronger and Better from a Crisis, writes, “Each sees the problem from his or her unique perspective.” Every employee has his or her own definition of a problem. Knowing how to deal with employees as individuals will go a long way in meeting goals.
       A good knowledge base from the administration is helpful in your purpose to do a good job. One would hope the DON and administrator understand what X, L, C, B, and A mean in terms of RUG levels. A knowledgeable MDS coordinator is a valuable member of the interdisciplinary team. I think by now all administrators understand the Prospective Payment System (PPS) and how the MDS impacts payment. One would also expect the administrator to understand the hierarchy of the RUG scores.
       Organizational structure for MDS coordinators also determines if the MDS coordinator fills in for a call-off or when the unit is short-staffed. Some MDS coordinators are used in other capacities. Their jobs are such that priorities are changed by the week. Many of the nurses who report to the administrator may not be involved in clinical time. In summary, the MDS coordinator’s job may basically be the same around the nation. But at the same time, it is different in every facility and company.

Q&A 

       Q: How long does it take to do an admission MDS? (licensed practical nurse, Oregon)
       A: It varies. It sometimes takes me 30 minutes just to gather information, meet the resident, and talk to staff. Many MDS coordinators do their own limited physical exams and exams of wounds. I try to see residents in multiple settings so as to get a well-rounded idea of how the resident is doing. The MDS coordinator checks all documentation, the medication and treatment administration records, certified nursing assistant (CAN) documentation, and rehabilitation notes. One must read every line of hospital records and every line of charting. The coding takes some time, depending on how many details there are to code. So, it might take 60 minutes or longer to code an MDS. The number of Resident Assessment Protocols (RAPs) triggered determines the amount of time it takes to complete them, but an hour is about average. Printing takes time, and then one must gather signatures and file, all of which takes time.
       Q: I’m looking around for another job in the city. What should I be considering? (registered nurse, California)
       A: Before you take on another MDS coordinator job, ask yourself if the new position is manageable There must have been a reason why there is an opening. If the new expectations of the company are too high, it might be impossible to complete the MDSs in a timely manner. Ask about flexibility, management responsibilities, work hours, salary, and chain of command. Since you are experienced, you can judge if the job meets your needs. I wouldn’t take any job unless it did. As with any job, inquire about benefits, vacation, retirement options, etc. Also, look at the reasons you are leaving your current position. Do some of the same issues exist? The grass is not always greener.
       Q: I don’t get along with my coworker. She’s part of the team, and I have to talk to her on many occasions. What should I do? (licensed practical nurse, Oklahoma)
       A: Here are some solutions that may help. First, during formal meetings, have an agenda item, such as discussion of care or quality improvement (QI) items. This will allow it to be directed to care of the resident, not at a direct attack of the person. Or, discuss the situation with the coworker and the human resource director in order to clear the air and come to a resolution. Or, talk to this person’s supervisor and discuss the problem. He or she may be able to shed some light on the situation. You don’t have to have coffee with this person, but you do need to maintain some sort of a working relationship.
       Q: What hours do MDS coordinators work? (licensed practical nurse, Arizona)
       A: Many coordinators work their own hours. They may work day shift, either 6 am to 2 pm or 7 am to 3 pm. Some work business hours, which may be the traditional nine to five. I know one nurse who works 4 am to noon. It’s easy to be caught up in working more than your eight hours, and it’s easy to be engulfed in our work and work overtime to get work done if you’re salaried. It’s easy to fall into the “there aren’t enough hours in a day” routine and work 12 hours just to get work done. It’s okay for some, but if you are salaried, it may lead to burnout. We all have to realize that there will be busier times than others. All of us try our best to determine how to manage our time, but supervisors must also deal with periodic problems. Being salaried versus hourly also makes a huge difference, as you may not have an option about your hours.