​Data, data everywhere, but don’t know what to think? Don’t worry, many directors of nursing services (DNSs) feel this way. Some days all the data can be nerve-wracking, especially when the person collecting it doesn’t know what to do with it. This article will help the DNS develop a process for evaluating the data, determining what information is pertinent, and deciding how to follow up.

The Importance of Data

Data can support decisions about the nursing department by revealing current situations, trends, and predictions, along with potential risks. Data can also offer insight into the cause of an issue. The bottom line: the DNS can’t perform the job effectively without data. The key is to know what to do with the data once it is available.

Triage the Data

We tend to associate triage, assessing the urgency of a situation, with a hospital emergency department or a wartime battlefield. But it is also the first step when determining what problem to tackle first. It’s the process of prioritizing information based on its level of importance.

When a facility has multiple concerns that require investigation, the DNS must triage and review those areas that pose a higher risk first, such as falls with injury or pressure injuries. Then those areas with lower risk or less substantial changes are reviewed. When triaging, each area should fall into one of these categories:

• Level 1: Poses an immediate risk to the safety of residents or the facility (e.g., an issue with fire safety or water that is above acceptable temperature range).
• Level 2: Poses a high risk to the safety of residents or the facility (e.g., a high rate of falls with injury or pressure injuries).
• Level 3: Poses a possible risk to the safety of residents or the facility (e.g., a high rate of urinary tract infections).
• Level 4: Poses a low risk to the safety of residents or the facility but needs to be addressed (e.g., late Minimum Data Set assessments).

When determining what problem areas to address next with corrective action, it is not possible to rectify all areas at once. That would be overwhelming. Select two or three with the highest priority, based on the triage, to work on at one time. After correcting one, proceed to the next one on the list. Consider delegating items that fall into levels 3 or 4.

Assess the Data

Nurses assess residents to gather data either to determine a nursing diagnosis or to relay that information to facilitate a physician’s diagnosis. Once the nurse identifies a problem, he or she can implement a treatment. This is the same process to use when reviewing an area for improvement. The DNS must assess the system and gather information to conduct a full analysis that can help diagnose the problem. For example, if pressure injuries are an identified problem, the DNS needs to review those residents with pressure injuries and conduct a comprehensive review of their medical records to ensure the following:

• Appropriate care is being provided to each resident.
• The standard of care is met.
• Staff are following facility policies and procedures.
• Staff identified changes in the resident’s condition and followed up on them.

The DNS should then take this assessment a step further with a proactive approach and review those residents at risk of developing a pressure injury. This strategy facilitates identifying and correcting any issues before they impact the residents or facility. Any issues found during the audit should be corrected.

Next, the group of residents should be analyzed to identify any trends, gaps, or concerns. Are pressure ulcers noted on a particular unit? Does equipment such as mattresses or chair cushions need replacing? Follow up on these to implement sustainable corrections. Conversely, in some areas, staff may be excelling, such as ensuring preventive devices are in place per the care plan. Praise them for these successes.

The final step of the assessment is to review the correlating policy and procedure, especially important when the policy or procedure is not being followed. If a practice is deficient, such as preventive skin interventions not put into place in a timely manner, review that portion of the policy and procedure first. Then ask these questions:

• Is it current with regulatory requirements?
• What portion of the policy and procedure was not followed that led to the issue?
• Why was the policy or procedure not followed?

Conduct a Root-Cause Analysis

Identifying the cause of the problem is paramount before implementing any intervention. Initiating solutions without knowing the root cause(s) of the problem or underperformance can be likened to washing the car and hoping it will fix the alternator.

When conducting a root-cause analysis (RCA), ask this question: “What changes can be made that will lead to an improvement?” The proposed changes should directly relate to the root cause. An RCA focuses primarily on inadequate processes or systems rather than on individual performance. It enables the organization to identify improvement strategies and thus decrease the likelihood of recurring incidences.

Determining the root cause(s) needs to emanate from an objective review of the system or process. The investigator should ask two questions:

1. Would the event have occurred if this cause had not been present?
2. Will the problem reoccur if the cause is corrected or eliminated?

If the answer to the questions is “no,” the root cause has been identified. If the answer is “yes,” the investigator needs to search further for the contributing factors.

Correct the Problem

After identifying the root cause of the problem, it is time to create sustainable interventions. They may include a change in equipment or staff education. It is crucial to choose the appropriate intervention or corrective action that tackles the underlying root cause of the problem.

The Guidance for Performing RCA with Performance Improvement Projects (PIPs), from the Centers for Medicare & Medicaid Services, describes three types of corrective actions: strong, intermediate, and weak. Aim for those corrective actions that are strong or intermediate when possible. Stronger actions are those that change the system and don’t allow for recurrence. The DNS must then determine if the correction needs a full-scale performance improvement plan or a simpler corrective action plan.

Quality Assurance

After completing the review and implementing correction of the issue, it’s time to ensure those changes stay in place to sustain the improvement. The best way to achieve this goal is through the facility’s QAPI program, a data-driven proactive way to improve quality of life, care, and services in a nursing facility. To succeed, this approach must include surveillance of the interventions implemented to sustain or improve the area. Any issues noted during the surveillance need to be addressed in a timely manner.

Although following these steps described here doesn’t diminish the amount of data the DNS receives, the ability to triage and prioritize the data will make it much more manageable.

Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT, is curriculum development specialist at the American Association of Post-Acute Care Nursing (AAPACN).