* ECPN * January/February 2001

Skin Care
Building Skin Assessment Teams for PPS and Survey Success

Nancy Day, RN, CRRN, CLNC

Tracy Kania, RN, BSN, CRRN

The movement from cost-based reimbursement to the prospective payment system (PPS) has obliged long-term care consultants to consider the facility's bottom line and to recognize that sound business principles are indispensable for the facility's financial viability. At the same time, the consultant needs to ensure that the provider's cost-containment program adheres to professional standards of care. The consultant must be ready to face this challenge and provide a strategic direction for their clients.

An effective principle that assures cost containment and adherence to standards of care is building an interdisciplinary skin assessment team. Natalie M. Quick RN, BA, CWOCN, and Director of Nursing at Marlboro Park Hospital in Bennettsville, South Carolina, recommends such a team. Ms. Quick advises that the team's services can include establishment of preventative protocols; development of wound care protocols; assessment, oversight, and documentation of treatments to support the MDS and the plan of care. The team could also participate in the reassessment and redirection of treatments in poorly responding wounds; incorporation of standards into the facility's wound care policies and procedures; and provisions of educational programs to direct care staff.

Ciaburri (1998) defines building the team as equipping the people of the organization with the necessary information, skills, and competencies to leverage their collective think power. Certainly, the clinical consultant is in a unique position to assist in the design and building of the skin assessment team. Suggested disciplines for the skin assessment team could be wound care nurse, staff nurse, physical therapist, dietitian, medical director or attending physicians, and social services.

Focus should be on furnishing the team with specific skills for working efficiently together, discussing issues, identifying problems, and creating solutions. Tools, such as brainstorming, weighted voting, cause/effect analysis, the roles of the leader, facilitator, and timekeeper, as well as a number of other techniques for managing efficient team meetings, can be introduced.

The consultant can propose a strategic direction for the interdisciplinary skin assessment team. Directing the team challenges each participant to utilize his or her expertise and provides both the individual and the team a sense of purpose. Also, in providing a strategic direction, the consultant can encourage the team in development of the team's mission statement. Once the mission statement is defined, the team should identify problem care areas that are incongruent with the mission statement. Of course, the consultant will often identify concerns through his or her consulting audits that are directed to the skin assessment team for further review and action. You can never have too many eyes checking quality.

Even more intricate than problem identification is deriving a solution for the problem. Again, the consultant brings to the team invaluable insight and experience for development of an effective plan of correction. The consultant can advance the team forward to achieve its mission.

Frequently, part of the solution to the problem is education and training. With the advent of PPS, facilities often cut education and training budgets. It has been said, "If you think education is expensive, try ignorance." Education and training are the keys to avoiding poor survey outcomes and legal liability, not to mention enhancing the resident's well being. Bridging the skills gap through education and training is the essence of consultation and the skin assessment team. Quite often the consultant is the catalyst that jump starts the team; the team then has an ongoing commitment to keep the staff and residents educated to assure quality care and services are continued. Another important role of the skin assessment team is to establish preventative of treatment wound protocols. Prior to enacting preventative or wound care protocols, interdisciplinary skin assessment teams need to be acquainted with regulatory standards outlined by HCFA and treatment guidelines, such as those issued by the Agency for Health Research and Quality (formerly known as Agency for Health Care Policy and Research--www.ahrq.gov) and by the American Medical Directors Association (www.amda.com). These agencies have designated what is accepted as reasonable (i.e., the standard of care). Therefore, it is vital that these guidelines are incorporated into the facility's protocols. Another logical area where the clinical consultant can bridge the skills gap is in clinical documentation. Because clinical documentation must be consistent with the MDS, it is essential that the interdisciplinary skin assessment team understand HCFA's interpretation of MDS items. The team may implement outstanding protocols and still not be paid justly if the documentation is inconsistent.

Following the requisite training, the consultant's services are still needed to objectively monitor the team's progress and provide constructive feedback. If the consultant expects high standards of care and expects the team to meet them, the consultant must be able to articulate to the team how their efforts have contributed to the facility's goals. In conclusion, the skin assessment team can play a vital part in assuring quality of care and quality of life for the resident as well as positive survey outcomes for the facility. ***

Acknowledgment

New Day Professional Services would like to thank Natalie Quick, RN, BA, CWOCN, for her contribution.

References

1. Ciaburri PL. Building the team or team building? There's a big difference. Rough Notes 1998;141(1):84–5.

Ms. Day is the president and Ms. Kania is the vice president of Clinical Services at New Day Professional Services. New Day Professional Services provides education and consultation to long-term care facilities and organizations nationally. For more information, call (803) 796-7835.