Just one more question

Like Lieutenant Columbo, the great TV detective, Long-Term Living

columnist Gary Tetz (Funny You Should Ask) always has one more question. In this bimonthly feature, he talks with long-term care leaders about anything that pops into his mind. He’s as surprised as you are that they’ll speak to him.

This Month’s Victim:

Diane Carter, RN, MSN, CS

President and CEO

American Association of Nurse

Assessment Coordinators (AANAC)

Diane Carter started her career in long-term care more than 30 years ago as a nurse aide, then as a director of nursing in a Denver nursing home. She’s seen a lot and knows a lot. And since I have seen very little and know almost nothing, I figured we should talk.

Prior to forming the American Association of Nurse Assessment Coordinators (AANAC), she was the associate director of the Colorado Association of Homes and Services for the Aging, and worked with the Colorado Health Care Association, teaching more than 300 workshops for providers. She also served with the Colorado Department of Public Health.

In a past life, she’s been the RAI coordinator for the State of Colorado, a Health Care Financing Administration (HCFA) instructor, and an advisor on quality indicators. Her work with the Center for Health Policy Research in the early 1980s led to the development of the MDS.

When I talked to Diane back in February, the weather was fine outside her Denver office. But it looked bad where she was going.

You’re not in a snowstorm, right?

No, but I’m supposed to be going to Baltimore tomorrow for the Pioneer Network meeting. And they are.

I’m no psychic, but I don’t think you’ll get there.

This could be the first time in 35 years of almost nonstop travel in my job that I’m not going to make it.

And that’s ironic, because it’s for the Pioneer Network. Do you think the pioneers who built our country would have let a little snowstorm stop them?

(Gasp) You are so right.

Not that I’m advocating unsafe winter travel. I’m not.


And of course, the pioneers were in wagons, so it was a whole different set of travel challenges.


You told me you’ve had some bad experiences with the media before, and are a little nervous. What happened?

I worked at the Colorado Department of Health years ago. Whenever there was a huge issue with a nursing home, they would call and grill us about our work.

This will not be a grilling. With your suspicion of the lame-stream media, I was thinking perhaps you had served as governor of Alaska.

I haven’t. But I’ve been to Alaska recently on a trip.

Did you see Russia while you were there?

I didn’t.

You founded the AANAC. That’s a lot of A’s-even for me as a Canadian. But what does your organization do for this profession?

We support nursing leaders at all levels, from corporate to facility. We give them the information they need to do their jobs, and do them well. It’s very pragmatic-the kind of information that gets you to 5 p.m. and helps you survive. That’s what our members tell us. We also have a rather large online discussion group of close to 800 nurses talking about this stuff night and day. It makes you wonder if any of us have a life.

I understand AANAC just completed a needs assessment for nurses. What did you find out?

What I concluded from the research was that the word for this decade is “accountability.” It’s increasingly clear that the MDS, which was traditionally seen as a compliance/reimbursement activity, now presents a much greater opportunity to understand accountability for the facility, in terms of survey and quality indicators-all those things that seem to drive nurse leaders crazy.

It’s become far more critical to measurement of improved and consistent outcomes for corporate consultants, the DON [director of nursing], and other nurses in the building. When we started 10 years ago, it was sort of, “Well, we have to fill out this form.” Now that’s all changed.

Are nurses feeling overwhelmed with this explosion of information and accountability?

If they don’t understand the uses of the information and how to roll that into improvement of care, it can be viewed as just one more thing they have to do in the day. But for those who understand the data and the multiple purposes of the MDS, it can be very useful in understanding what’s going on with their residents and ensuring better outcomes.

You started your career as a DON, so you’ve been dealing with this for a long time.

Yes, I started in a nursing home. I remember they ran an ad that said, “Must care, and must know regulations.” Well, I cared, but I certainly didn’t know the regulations. And, of course, a state survey team came in immediately. I was standing over their shoulders saying, “What are you all looking at? I wish I’d gotten a playbook on this before you arrived.”

It was frightening. So I think I have a clear understanding of what that feels like to scramble when state surveyors walk in.

You seem to actually like this MDS stuff.

Yes, I don’t know what it says about my life, but I’ve been doing this work for more than 30 years. And I do actually like it. It’s scary.

What’s most different about being a DON now compared to when you started?

It’s probably the issue of accountability. When I was the DON, we had an annual survey, but I didn’t see any oversight agency for another year. And I didn’t have to deal with so many of the staffing and legal issues nurses deal with now. Also, the transparency is so great with Nursing Home Compare, Five-Star-all of these systems. It’s all out there for everyone to see. It’s a completely different world.

And is the care better?

I think in general, yes. There’s a whole new level of thinking about resident choice and voice, and understanding where that leads us in terms of care.

When I started in this profession a bazillion years ago, there was just nothing going on in the daily life of residents. I worked in a nursing home while I was in high school, and recruited my friends to take in cookies for a Valentine’s party because there was no activities department. So when you say, “Have things improved?” Dramatically.

What change has contributed most to a higher quality of care?

Probably the increased regulation. Having come through the void personally, there is some truth to the idea that regulation provided a model of care that was really important. I certainly can tell you that as a teenager working in a facility, I adored those residents, and still can name almost all of them. But there was definitely an element of warehousing people. And we are very far beyond that now.

Can we do better? Sure. And I have to say I am really impressed with MDS 3.0. It goes very much to voice and choice, and capturing what’s important to the resident and making sure that happens in everyday life. There’s a lot of merit to that. Sometimes I think we get so sidelined by the data that we forget that care is really what it’s all about.

I noticed a picture of a bunch of you holding an AANAC sign on Capitol Hill. What were you doing there?

CMS [Centers for Medicare & Medicaid Services] calls us all the time, and we have a lot of input on policy issues that affect nurses. But we’re trying to be more proactive instead of reactive to the regulations. So our board of directors and some of our key leaders went to Capitol Hill and met with our respective congressional representatives. We just wanted them to be aware of AANAC and what we do, and we took them some…


Yes, we took them punch and cookies. No, we gave them bullet points.

A steaming platter of bullet points.


Let’s talk quickly about the Five-Star Quality Rating system. I interviewed an administrator recently who had just found out they had received five stars. They felt pretty good about that. What do you think?

I would say I do have questions. Having worked with the state health department, I find it’s more heavily weighted toward state survey results, and there have always been some issues with the reliability and validity of that process. On the staffing side, I don’t think there’s any question that it’s hard to improve outcomes of care when you don’t have enough staff. But at the same time, I have questions about where the system came from.

You’re not suggesting I call her back and say they didn’t deserve it, are you?

No, but the stars shift so dramatically that you have to wonder a little bit about it. What do they say, “Garbage in, garbage out? Data in, data out?” There are some important adjustments that need to be made, and the biggest one I hear is how a facility can be two stars this time and suddenly four or five the next.

That’s the society we live in, though. We want everything rated.

As a person who typically loves data, I bring a lot of skepticism. Maybe that’s what happens when you know too much.

What rating would you give this interview?

Oh, at least a 5…on a scale of 1 to 10.

At first I was elated, then you changed the scale. That wasn’t fair.

You always have to first define the scale.

You’ve devoted your whole career to this, and a lot of people appreciate what you’ve done to make the system better.

The one thing I’m positive about is that nurses feel an absolute sense of mission. They are madly in love with their residents and the care. And I think, at times, all of these systems strike us as, “How could you question our accountability? Why would we do this if we didn’t absolutely love it?” But frankly, I don’t know how to avoid all this measurement.

So next time you chat online with your 800 nurses, what are you going to tell them about this interview?

That it was a splendid experience. And speaking of unreliable data, now I would give it at least an 8.

My rating jumped just like that?

It was your endearing personality. If I didn’t have a sense of humor, I have no idea how I would have remained in this field for 35 years.

It’s been great talking to you.

Now I’d give you a 10.

Long-Term Living 2010 August;59(8):49-52

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