While the director of nursing services (DNS) and other nurse leaders should keep residents at the heart of every decision, data should provide the framework for those decisions to help residents achieve the best possible quality of care and quality of life, suggests Laurie Laxton, RN, BSN, RAC-CT, CMAS, QCP, IP-BC, a principal product manager at the healthcare software and analytics company Inovalon in Bowie, MD.
“Data tells a story,” says Laxton. “If you pay attention to the clues in this pie graph or that line chart the same way that you do if you are watching a murder mystery on television, you will be able to see a clear, unbiased picture of what is happening with your residents and the care that nursing staff and the rest of the interdisciplinary team are providing. The key is to gain the skills to learn, ‘What is this data telling me?’”
Laxton and Michelle Karl, MSHI, MBA-HC, BSHA-LT, LVN, an Inovalon product manager, will co-present the March 19 session “Let Your Data Do the Talking” at the March 17 – 20, 2026 AAPACN Conference in Orlando, FL, to help nurse leaders gain advanced skills to both access and interpret data.
Data often goes unused
The Centers for Medicare & Medicaid Services offers multiple data reports via the Internet Quality Improvement and Evaluation System (iQIES), says Laxton. “You can access data, for example, on MDS submissions, the Nursing Home Quality Initiative (NHQI) quality measures (QMs), the Five-Star Quality Rating System, Skilled Nursing Facility Quality Reporting Program (SNF QRP) submission compliance rates and QMs, and Skilled Nursing Facility Value-Based Purchasing program (SNF VBP) performance scores and QMs.”
Note: Learn about the SNF VBP reports at CMS’s Confidential Feedback Reporting & Review and Corrections page. Find out about other CMS reports in Appendix A, “List of Reports Generated on Demand,” of the iQIES Reports User Manual and the News and Updates section of the QIES Technical Support Office (QTSO).
In addition, most clinical software systems provide some level of data reporting and analysis, says Laxton. “And, some larger organizations are even building their own internal data dashboards.”
The problem is that many nurse leaders are not taking full advantage of the available data, says Laxton. “Often, nurse leaders use the bare minimum functionality instead of developing the skill sets to run and interpret the ‘bells and whistles’—in other words, the most useful, value-added data reporting and analytic tools—that CMS or their own clinical software offers.”
Why do nurse leaders need to prioritize data?
The failure to use data as a core management tool on an ongoing basis can put nurse leaders—and nursing home operations—at a significant disadvantage for several reasons, starting with survey, says Karl. “Data is integral to the survey process. Every bit of your data, including MDS data, drives your survey outcomes, and CMS hands that data to the state surveyors prior to them ever entering your building.”
Note: The Long Term Care Survey Process (LTCSP) Procedure Guide (available in the Survey Resources folder here), the Offsite Prep and Resident Pool Initial Screenings sections of the iQIES Survey and Certification (S&C) Manage a Survey: Long-Term Care Facilities User Manual, and Appendix A, “List of Reports Generated on Demand,” of the iQIES Reports User Manual explain some of the data that surveyors access before and during survey. For example, surveyors review the facility’s repeat deficiencies, Payroll-Based Journal (PBJ) staffing information, and MDS Indicator Facility Rate Report, which lists MDS indicators associated with selected residents, as well as the total count and total percentage of residents with a specific MDS indicator. Examples of MDS indicators include when the resident: is on dialysis or hospice, has a tracheostomy, is on a ventilator, has a major infection, has experienced a significant weight loss, has been rehospitalized, or has depression.
“The lesson for nurse leaders is that you need to know the same data that the survey team will know—before they arrive,” says Karl. “If you know what your data is, then you can be in control of your survey to an extent.”
Of course, nurse leaders cannot completely control the human element, points out Karl. “For example, a surveyor may observe a certified nursing assistant (CNA) whom you have trained and educated on your infection prevention policy and procedures fail to perform hand hygiene when they leave the room of a resident on transmission-based precautions, resulting in a citation.”
However, nurse leaders who really take the time to regularly monitor MDS and other data will understand, for example, which residents the surveyors are most likely to observe and interview, says Karl. “Then, you can finetune your survey preparation. Going back to the scenario of the CNA who didn’t perform hand hygiene, you could proactively work to reduce the chances of that occurring by perhaps making sure that staff can easily access hand hygiene stations in rooms where residents have a major infection and asking your infection preventionist to audit hand hygiene and other infection prevention practices used with those residents in your building.”
In addition to survey preparation, effective data management can help nurse leaders stay on top of QMs used in the Nursing Home Quality Initiative and Five-Star Quality Rating System, the SNF QRP, and the SNF VBP, says Laxton. “Running some reports to understand, for example, which residents are triggering specific MDS-based QMs can help you work with the nurse assessment coordinator (NAC) to boost MDS accuracy.”
Better MDS accuracy in turn may improve accuracy in multiple areas, says Laxton. “These include facility performance in the NHQI, SNF QRP, or SNF VBP QMs; Five-Star ratings; care area triggers (CATs), care area assessments (CAAs), and care plans; and payment under the Patient-Driven Payment Model (PDPM) and state Medicaid case-mix systems. Going even further downstream, ensuring more accurate QMs across all three programs allows you to better target the work in your Quality Assurance and Performance Improvement (QAPI) program, which also can help your survey preparation.”
“The bottom line is that staying aware of your MDS data—what every QM looks like and what data surveyors will focus on—is what will keep you where you need to be,” adds Karl. “That’s true whether you are looking at the SNF VBP, the SNF QRP, Five-Star, or survey.”
Outside of the MDS, one example of an important data source for nurse leaders is safety reporting from the facility’s risk management program, says Laxton. “Your safety reporting offers many data points (e.g., on falls), whether you collect that information via software or on paper. Even if you are paper-based, you can at least use Microsoft Excel spreadsheets to either assist you with a data-driven root-cause analysis or a trend report that you can use in your QAPI program.”
AI can assist, but it’s not the entire answer
Artificial intelligence (AI) is the buzzword in nursing just like it is basically everywhere, notes Laxton. “Two critical points to know about AI are (1) it doesn’t do all the work for you collecting and analyzing data, and (2) you can’t always trust AI because it can pull information from untrustworthy sources on the Internet.”
A good way to look at AI is as an excellent research assistant, suggests Laxton. “For example, AI can filter and search a great amount of data and summarize it for you. As a nurse leader, however, you still have to act as the subject matter expert and read and analyze the data right alongside the AI. You need to develop some expertise in data analysis to thrive in the post-acute care landscape—the same way that nurse leaders in acute care have done.”
What to expect at conference
During their session, Laxton and Karl will use screenshots of CMS reporting options, software vendor reporting options (including not just Inovalon but its competitors as well) to show attendees examples of available charts and reports, says Laxton. “Just as importantly, we will use audience participation tools to invite them to learn to solve that mystery of ‘What do you see in this data?’”
Laxton and Karl also will do a deep dive into several types of data, says Karl. “We are going to look at MDS data, infection reporting data, and risk management/safety data. You should leave the session understanding how you can use software not only to identify concerns from these data sources but also to drive improvements.”
The risk management section of the presentation actually builds on the Feb. 12, 2026 AAPACN webinar “Beyond Crisis Mode: A DNS Blueprint for Proactive Risk Management” from Denise Winzeler, RN, BSN, LNHA, DNS-MT, QCP-MT, director of education and certification strategy, says Laxton. “This is step two of that lecture. Denise provided the blueprint for putting together a strong risk management program, and we are going to take that to the next level by showing you the actual data that you would need to act upon.”
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