MDS 3.0 and the DON

The words “MDS 3.0” undoubtedly trigger a number of disparate thoughts in a director of nursing’s (DON’s) mind. This is going to be a year of change for nursing homes, and much of it will be centered on implementation of this new version of the Minimum Data Set, scheduled for October 1, 2010. Since it is the foundation for care planning, Medicare Part A reimbursement, quality monitoring, and survey activities, the facility team’s mastery of the MDS 3.0 will be a key to success-and a significant challenge.

At a glance…

Implementation of the MDS 3.0 offers the perfect opportunity to improve the quality of care in a facility by improving the quality of assessment and care planning for the 20 care areas involved. The DON must assume the leadership role.

The DON’s leadership will be critical. There is a lot that is new with this MDS. In fact, so much is new that it should be approached as a brand-new assessment tool as opposed to looking at it as simply an update to the MDS 2.0. There will be much for the team to learn, a lot of analysis for the administrative team to conduct to understand the reimbursement implications, and some re-evaluation of facility systems to take place. In that context, “opportunity” might not be the first term a DON associates with MDS 3.0, but, nonetheless, the opportunities presented by MDS 3.0 implementation can be very exciting. They are opportunities that can lead to significant improvements in the quality of care and quality of life for the residents.

Culture change

The MDS 3.0 provides a direct and important connection to culture change. Through the scripted interviews that are integral to the assessments of cognition, mood, activity and routine preferences, and pain, the staff can learn about the resident’s own feelings, needs, concerns, and priorities, and they can learn it from the resident’s own words.

The testing of the MDS 3.0 in volunteer nursing homes in eight states showed that about 85% of residents were able to complete the interviews, including cognitively impaired residents. The message is that even the most cognitively impaired residents retain the ability to communicate about issues that are important to them. Thus, this MDS 3.0 interview process presents a huge opportunity to improve each resident’s quality of life by learning about and then honoring what is important to the resident. But these interviews represent a significant change in MDS process in most facilities, and it will require dedicated leadership from the DON to transform the MDS from a paper compliance into a critical tool for resident-centered, resident-directed care. The Long-Term Care Facility Resident Assessment Instrument User’s Manual contains detailed instructions for each interview in Chapter 3 as well as very helpful information about interviewing skills to elicit the resident voice in Appendix D. But without strong leadership and clear goals, it is likely that many folks will simply transfer the processes they use with the MDS 2.0 to the 3.0-and for many facilities that will be a significant missed opportunity.

There are some steps DONs can take to get this ball rolling:

  • Familiarize yourself with the scripted interviews, the instructions in the manual, and the information in Appendix D, and work with the staff responsible for the interviews to help them hone their interview skills. Try a couple of interviews with residents yourself.

  • Ensure easy availability of a private location for the interviews to take place. Most residents live in semi-private rooms, which don’t offer much privacy as far as conversation is concerned. So it’s going to be important to figure out how to make this happen for each and every interview.

  • Help the staff to understand the importance of ensuring that the resident can hear as well as possible. This might be as simple for some residents as ensuring that the ambient noise is minimal or that their hearing aids are in good working order. But for some residents with hearing loss who do not have hearing aids, the availability of a hearing amplification device can be the determining factor in making the interview meaningful.

  • Once the information is collected from the resident, work with the staff to ensure that it translates into care planning and care delivery specific to the resident’s stated preferences, needs, desires, and values. If your facility is not already on board with culture change, this will undoubtedly require redesign and revision of many resident care systems to change the focus from facility schedules, routines, and preferences to honoring each resident’s preferences and needs. This, too, will require strong leadership.

The MDS 3.0 offers a new opportunity when it comes to the quality of assessments, too. The MDS process isn’t changing. The MDS 3.0, like its predecessor, is a screening tool. It will alert the team that a resident may have problems in any of 20 different care areas, such as delirium, mood, pain, etc. When any of those care areas are flagged, or triggered, based on selection of a particular answer option on the assessment, that means that a further, more in-depth assessment of the care area must be conducted. This is to determine the nature of the problem, the root causes, and contributing factors so that a resident-specific care plan can be developed. This will assist the resident in overcoming the problem as much as possible to attain or maintain his or her highest practicable level of well-being. This process has been mandated ever since the MDS was first implemented via the Omnibus Budget Reconciliation Act of 1987, but it often hasn’t been carried out appropriately nor has its connection to quality been well understood.

Perfect opportunity

Implementation of the MDS 3.0 offers the perfect opportunity to improve the quality of care in a facility by improving the quality of assessment and care planning for the 20 care areas involved. For example, a resident who normally finds his way around the facility has been a bit disoriented at times during the look-back period for the MDS, even getting lost at times. One approach would be to care plan safety and reorientation interventions. The other approach would be to conduct a complete assessment for delirium, the care area triggered by acute change in mental status, using evidence-based assessment tools to determine the underlying causes of the problem for this resident (such as side effects of a new medication, infection, low sodium level) so they can be treated and maybe even eliminated. At the same time, a thorough assessment would be conducted of the risks to the resident now that he has this problem. When so much detailed information is collected about the resident’s status, the care plan almost writes itself. It becomes a very resident-specific plan of action to tackle the identified issues.

This is the kind of assessment that should take place regardless of the healthcare setting and regardless of whether the problem is in one of the 20 care areas included in the MDS 3.0 Care Area Assessment process. It is the standard of care. But the standard often isn’t met in many facilities across the country. The catalyst that can make it happen is the DON.


The American Association of Nurse Assessment Coordinators (AANAC) is a nonprofit professional association representing nurse executives working in the long-term care industry. AANAC is operated by nurses for nurses and is dedicated to providing members with the resources, tools, and support they need in their specialized role of leaders and managers in long-term care.

AANAC offers the nurse executive:

  • The opportunity to discuss common challenges and problem-solve with peers and experts from across the country via a widely attended online discussion group

  • Quick and easy access to current long-term care news, regulatory updates, manuals, and publications

  • Weekly e-mail reminders about important dates, deadlines, and current events

  • Educational programs and CEs encompassing the essential job functions of the long-term care nurse executive

  • A weekly newsletter addressing tough issues and topics of current interest on the impact of regulation on facilities

AANAC is the organization chosen by successful leaders in long-term care. To join or get more information about AANAC, visit or call (800) 768-1880.

Optimal implementation

Overall, the MDS 3.0 also provides a great opportunity for identifying resident care and organizational processes that could benefit from improvement. Put together a team to take a look at the MDS 3.0 and to propose processes for meeting the requirements and optimizing its benefits. This may include studying the facility’s MDS 2.0 processes to identify what works and what doesn’t. That includes everything from staffing patterns to information sharing to care conferences and everything in between. As a result of this effort, the facility can develop the best systems and processes for optimal MDS 3.0 implementation.

Taking advantage of all of these opportunities can significantly improve the quality of care and the quality of life for residents. It can’t be done by one person-and it cannot be done without the DON’s leadership.

Rena R. Shephard, MHA, RN, RAC-MT, C-NE, is Executive Editor of the American Association of Nurse Assessment Coordinators (AANAC). She can be reached at (858) 592-6799, or for more information, visit

To send your comments to the editor, please e-mail

Long-Term Living 2010 March;59(3):54-55

Topics: Articles , Clinical , Facility management , MDS/RAI