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Service Delivery Innovation Profile

Prevention and Treatment Program Integrates Actionable Reports Into Practice, Significantly Reducing Pressure Ulcers in Nursing Home Residents


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Snapshot

Summary

The On-Time Pressure Ulcer Prevention Module standardizes documentation data elements and facilitates the use of weekly, actionable clinical decisionmaking reports to identify and track pressure ulcer risk factors by resident. These practices are integrated into everyday clinical workflow, allowing nursing home staff to intervene in a timely manner with at-risk residents. Based on its positive results, the program has expanded to other clinical areas and is now known as the On-Time Quality Improvement Program for Long-Term Care, or On-Time; it is a facilitator-directed quality improvement program that provides tools to improving clinical decisionmaking for pressure ulcer prevention, pressure ulcer healing, falls prevention, and prevention of inappropriate hospitalizations. On-Time provides a practical approach to identifying and managing high-risk residents by integrating the clinical decision support tools available in health information technology into frontline daily practices in long-term care.
The program has been shown to reduce pressure ulcer rates and lead to operational improvements, including reducing the number of documentation forms used, decreasing the amount of overtime needed to complete documentation, improving interdisciplinary communication, and increasing nursing home staff satisfaction. The implementation of the On-Time Pressure Ulcer Prevention Clinical Decision Support reports and associated process improvements was associated with a large and statistically significant reduction in pressure ulcer incidence compared with the incidence in nonimplementing facilities.

Evidence Rating (What is this?)

Moderate: The evidence consists of a prospective observational pilot study and subsequent implementation efforts allowing before-and-after comparisons of key clinical and process outcome measures, including pressure ulcer rates and documentation completeness and efficiency, as well as an evaluation study comparing pressure ulcer rate reductions in implementing and nonimplementing facilities in New York State.
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Developing Organizations

Health Management Strategies, Inc.; International Severity Information Systems, Inc.
International Severity Information Systems, Inc., is located in Salt Lake City, UT. Health Management Strategies, Inc., is located in Austin, TX.end do

Use By Other Organizations

As of September 2011, the program has been implemented in more than 90 nursing homes in California, Arizona, Ohio, New York, Pennsylvania, Wisconsin, South Dakota, Michigan, North Carolina, and the District of Columbia; these facilities were assisted by On-Time project facilitators. Some On-Time programs have been implemented with support from Departments of Health in New York, California, and Washington, DC. Also, 10 long-term care health information technology vendors have included On-Time standard documentation data elements and clinical decisionmaking reports in their products. In addition, the On-Time quality improvement approach has been used as a foundation to design and implement other On-Time quality improvement modules, including falls prevention and avoidable transfers to hospitals and EDs.

Date First Implemented

2002
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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

Pressure ulcers are common among nursing home residents and are associated with a significant clinical and economic burden. Although tools exist to predict, track, and treat pressure ulcers, they are often not well integrated into the existing workflow of nursing home staff—specifically, daily documentation and use of the information in clinical discussions.
  • A common condition, especially in high-risk residents: Estimates of the prevalence of pressure ulcers in nursing homes range between 2.5 and 24 percent of residents, with an average of 1.6 to 2.5 wounds per resident. Certain residents are at much higher risk than others. In fact, the overall incidence of pressure ulcers in nursing facilities is 0.2 to 0.56 pressure ulcers per 1,000 resident days, but the incidence is approximately 14 per 1,000 resident days among high-risk individuals. Approximately 70 percent of pressure ulcers occur in residents aged 70 and older.1
  • Considerable economic burden: Pressure ulcers may cost as much as $11 billion annually, owing primarily to the high costs of treatment.2,3 Treating a stage 2 pressure ulcer (a shallow ulcer or abrasion in which skin remains) costs at least $7,000, while treating a stage 3 ulcer, which has broken down the skin, reaching into subcutaneous tissues, can cost up to $15,000.4
  • Commonly used tracking tools of limited value to resident care: The Centers for Medicare & Medicaid Services (CMS) requires that nursing homes submit quarterly reports tracking a set of data known as the minimum data set; these data are collected and reported by topic area (e.g., nutrition, bladder incontinence, bowel incontinence, weight, activities of daily living). To meet these requirements, nursing homes have established daily documentation practices for certified nursing assistants (CNAs), typically using between 5 and 12 log books to document resident care. Although these log books help in meeting the requirements, they are impractical for planning care because they do not provide information to clinicians on the broad scope of issues faced by an individual resident that can contribute to the risk of a pressure ulcer.5,6

What They Did

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Description of the Innovative Activity

The On-Time Pressure Ulcer Prevention Module standardizes documentation data elements and facilitates the use of weekly, actionable clinical decisionmaking reports to identify and track pressure ulcer risk factors by resident. These practices are integrated into everyday clinical workflow, allowing nursing home staff to intervene in a timely manner with at-risk residents. Based on its positive results, the program has expanded to other clinical areas and is now known as the On-Time Quality Improvement Program for Long-Term Care, or On-Time; it is a facilitator-directed quality improvement program that provides tools to improving clinical decisionmaking for pressure ulcer prevention, pressure ulcer healing, falls prevention, and prevention of inappropriate hospitalizations. On-Time provides a practical approach to identifying and managing high-risk residents by integrating the clinical decision support tools available in health information technology into frontline daily practices in long-term care. Key program elements include the following:
  • Standardized, easy-to-use CNA documentation data elements: For a nursing home without health information technology, a team of frontline clinicians works together to streamline existing documentation and incorporate standard On-Time data elements. As a first step, CNA paper documentation forms are redesigned as a checklist-based consolidated form to document daily care and information relevant to each resident’s risk of pressure ulcers, including frequency of incontinence, use of disposable briefs, meal intake, weight changes, behaviors, and skin features. The documentation form is designed to be easy to use. It includes check boxes rather than spaces for handwritten notes, and information is organized to reflect CNA workflow. The CNA documentation template can be used to get started and can be customized to meet the unique needs of facilities, although most facilities use forms that are highly (90 to 95 percent) consistent with the content of the standard template. After consolidating CNA documentation on paper, each facility uses the health information technology of its choice to automate the collection of CNA documentation.
  • Actionable clinical decision support (CDS) reports: Staff members access On-Time clinical reports that support timely identification of resident risk and care decisions based on specific resident needs. The reports organize and summarize the data collected during the course of routine CNA documentation, providing resident-specific data and prioritizing residents based on resident pressure ulcer risk. Reports include the following:
    • Documentation completeness report: This weekly report summarizes CNA documentation completeness rates for each unit by shift; the report highlights documentation components that possibly require additional staff education. These reports are used to provide individualized feedback to CNAs and to design educational efforts centered on appropriate documentation.
    • Nutrition report: This weekly report provides resident-specific data on average meal intake for the current week and the previous 3 weeks, nutrition interventions (e.g., diet, supplements), weight gain/loss, date of last diet consult, history of pressure ulcers, and presence of pressure ulcers. The report stratifies residents according to risk, with high risk being defined as both decreased food intake and weight loss, medium risk as either decreased food intake or weight loss, and low risk as neither decreased food intake nor weight loss.
    • Behavior report: This weekly report lists the number of times a CNA observes a resident’s behavior, including biting, scratching, wandering, etc. The nurses and social workers can use this report to support their assessments and in followup with CNA staff.
    • High-risk triggers report: This weekly report lists residents who exhibit pressure ulcer risk factors such as weight loss, decreased food or fluid intake, bowel or bladder incontinence, presence of a Foley catheter, and low ambulation; total risk factors for the current report week are compared against prior week total risk factors.
    • Priority report: This weekly report identifies residents with changes from the previous week in five areas that place a resident at potential risk for developing a pressure ulcer: decreased meal intake, weight loss, increased incontinence episodes, change in or increased behavior problems, and new or worsening pressure ulcer. This report, often used in conjunction with other On-Time reports, offers the nurse a quick view of residents experiencing subtle or significant changes from the previous week that may be associated with pressure ulcer development.
  • Facilitated process improvement effort: Frontline teams at each facility collaborate with a project facilitator to use the reports to improve care processes through the following kinds of activities:
    • Discussing the reports at designated care planning meetings and using timely information on resident changes to alter care plans.
    • Holding 5-minute standup meetings with dietary staff, CNAs, and nurses (weekly huddles) to review residents at high risk for nutrition problems and adjust care plans accordingly.
    • Holding weekly rounds to serve as a functional review with rehabilitation representative, CNA, and nurses; these occur for residents at high risk for pressure ulcers to identify decline in activities of daily living, need for positioning, and other rehabilitation-related interventions.
    • Providing ongoing feedback focused on learning by posting reports on CNA bulletin boards.
    • Holding meetings with CNAs and social workers to discuss changes in behaviors and how they are related to eating or level of functioning.
    • Assisting with CMS minimum data set assessments.
  • On-Time Pressure Ulcer Healing Module: In 2009, On-Time was expanded to include a Pressure Ulcer Healing Improvement Program focused on monitoring pressure ulcer healing and risk factors that may be specific to the rate of healing and best practices for treatments of pressure ulcers. The project was designed to streamline and standardize wound assessment documentation and develop weekly wound reports to support clinical management and monitoring of wounds by facility or nursing units. The module includes reports to track ulcers that are stagnating or not improving. Key elements of the program include the following:
    • Bottom-up approach: A bottom-up approach includes frontline caregivers as integral members of the care team and important contributors to the documentation process to ensure that this approach to pressure ulcer healing becomes part of everyday practice in long-term care facilities and can be sustained in an environment of high turnover.
    • Standardized data elements related to wound and skin assessment and pressure ulcer treatments: Standardized data elements are related to weekly wound and skin assessment and pressure ulcer treatments.
    • Standard reports: There are three standard reports:
      • Existing pressure ulcers: This report provides the clinician with a comprehensive list of residents with existing pressure ulcers receiving weekly wound assessments and care. Clinicians use the report as a tool to track and manage resident pressure ulcer care. The report provides ulcer-specific information, such as ulcer location, size, and duration in days; other relevant clinical information is included, such as nutritional supplement use, weight loss, and total number of resident risk factors. Clinicians can compare ulcer progress with available benchmark data for similar ulcers.
      • Stagnant or worsening pressure ulcers: This report displays a list of residents with pressure ulcers that have been treated for more than 20 days and one of the following is true: (1) ulcer surface area is unimproved for two consecutive wound assessments; or (2) ulcer has worsened since last assessment, as recorded by nursing on weekly wound assessment. Clinicians use this report to help manage ulcers that remain unhealed 20 days after ulcer identification. Nurses report that a list of stagnant ulcers has not been readily available because of the need to calculate manually how long wounds have been treated; therefore, organizing and tracking stagnant ulcers was not performed routinely in the past.
      • Pressure ulcer quality improvement monitor report: This monthly report compiles pressure ulcer statistics from data captured by nursing on weekly ulcer assessment documentation. The report is an example to clinicians of how health care information technology can be leveraged to collect, store, and compile data for reporting; information in this report usually is compiled manually by nursing staff or quality improvement teams. Clinicians use this report for internal reporting and to monitor and analyze facility pressure ulcer development patterns and rates to formulate improvement strategies.
  • On-Time Falls Prevention Module: In 2012, the On-Time Quality Improvement Program for Long-Term Care was expanded to include fall prevention. The goals of the On-Time Falls Prevention Module are to (1) collaborate with nursing home clinical staff to design clinical decision support tools, (2) develop implementation strategies using fall prevention CDS reports to improve risk assessment, (3) identify residents at high risk for falls earlier and implement interventions, and (4) monitor fall risk before fall to prevent injurious falls. Key elements of the program are similar to other On-Time components and include using a bottom-up approach, agreeing on standardized data elements related to fall risk assessment, designing standard reports, and facilitating implementation strategies for using the reports. Five standard reports for the falls prevention program are as follows:
    • Fall prevention: high-risk report (1 report): This report is used to identify residents at highest risk for falls in a more timely manner than existing practices and to help trigger early prevention activities like referrals for physical therapy; consultations with physicians, dietary staff, etc.; and changes in nursing care plans. To accomplish this goal, the high-risk report utilizes fall risk factors embedded in daily and weekly nurse electronic documentation to profile risk factors and identify weekly resident changes. The report incorporates a blend of existing resident information recorded in quarterly minimum data set assessments and current resident information captured by nurses on 24-hour reports, in change of condition assessments, or in daily progress notes.
    • Falls quality improvement monitor reports (4 reports): The team designed a set of quality improvement monitoring reports to be used to support quality improvement efforts to monitor falls and support root cause analyses after fall incidents. These monitoring reports are a set of management tools that provide monthly and quarterly trended information for falls on each nursing unit to support quality improvement.
  • On-Time Avoidable Nursing Home Transfers Module: In 2012, the On-Time program was expanded to include the prevention of avoidable hospitalizations and ED visits. The goal of this new On-Time module is to develop evidence-based tools to identify, manage, and monitor multiple risk factors for hospitalizations and ED visits using an approach similar to that of the prior On-Time modules. Key elements of the program are similar to other On-Time modules, such as using a bottom-up approach, agreeing on standardized data elements related to risk for transfer to the hospital and ED, reports to help the care planning team identify residents at risk for transfer to hospital or ED, and facilitating implementation strategies for using the reports, including root case analysis of transfers when residents are treated and released. Five standard reports are as follows:
    • Transfer risk reports (2 reports): Using the transfer risk reports supports the multidisciplinary team by flagging changes in resident status and identifying residents at high and medium risk for transfer to hospital or ED. The transfer risk reports enable teams to establish daily or weekly processes for report review that enables clinicians to proactively and consistently identify residents at high risk for transfer. Transfer risk reports can be used in multiple existing or new meeting processes to identify residents at high risk for transfer to hospital or ED.
    • Quality improvement monitor reports (3 reports): These reports provide a comprehensive summary of nursing home hospitalizations and ED visits, the associated resident risk factors for each, and the key metrics at the facility and unit level. Quality improvement monitor reports comprise a set of three management tools that provide monthly and quarterly trended information on transfers to hospital and ED by facility or nursing unit. The quality improvement monitor reports help to (1) identify trends and patterns by nursing unit or facility; (2) compare trends across nursing units; (3) identify resident risk factors and recent changes related to transfer to hospital or ED; (4) improve timeliness of root cause analyses; and (5) provide summarized data on transfers to hospital or ED and possible root causes to improve prevention practices and identify need for programmatic changes.

Context of the Innovation

International Severity Information Systems, Inc., is a health services research organization based in Salt Lake City, UT, that develops infrastructure and tools to support clinical decisionmaking. The organization received an AHRQ grant to design and test an initiative to standardize best practice information into CNAs’ daily documentation in nursing homes and to prompt the use of this information in actual clinical decisionmaking. With support from Health Management Strategies, Inc., a health care consulting group that facilitates quality improvement, health information technology implementation, and clinical workflow reengineering, the company designed and implemented a 3-year prospective observational study involving 11 nursing homes in seven States (Pennsylvania, New York, Wisconsin, South Dakota, Texas, Michigan, and Ohio). Participating facilities varied in size from 44 to 432 beds and represented both rural and urban, as well as for-profit and not-for-profit, settings. All facilities served long-stay residents and had pressure ulcer prevalence rates higher than 8 percent. Based on the success of the study, the company received a second AHRQ grant to use health information technology to support the program. In 2005, the organization received a 5-year AHRQ contract to disseminate the program through Medicare Quality Improvement Organizations and State Departments of Health in California, New York, and Washington, DC.

Did It Work?

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Results

The program has been shown to reduce pressure ulcer rates and lead to operational improvements, including reducing the number of documentation forms used, decreasing the amount of overtime needed to complete documentation, and improving interdisciplinary communication. CNA satisfaction also rose as a result of the program. In a subsequent implementation effort, International Severity Information Systems, Inc., partnered with 4 quality improvement organizations and 21 nursing homes (approximately 2,500 beds) to implement the On-Time Pressure Ulcer Prevention Module, with results achieved in clinical outcomes, workflow efficiencies, and staff experience. The implementation of the On-Time Pressure Ulcer Prevention Clinical Decision Support reports and associated process improvements was associated with a large and statistically significant reduction in pressure ulcer incidence compared with the incidence in nonimplementing facilities.
  • Fewer pressure ulcers:
    • Pilot study: The pilot prospective observational study 11 pilot facilities in 7 States found that the program reduced pressure ulcer incidence and prevalence rates by more than one-third. As a result of better management of pressure ulcer risk factors, such as incontinence, poor nutrition, weight loss, and activity level, the percentage of high-risk residents with pressure ulcers decreased from 14 to 8.7 percent over an 18-month period.
    • Subsequent implementation: In the next phase of implementation (On-Time), overall, there was a 13 percent reduction in CMS's high-risk pressure ulcer quality measure 6 months post-implementation. For facilities with a high level of implementation, there was a 30.7 percent decline (from 13.1 to 9.1 percent) in the CMS pressure ulcer quality measure and a 42 percent decline in in-house pressure ulcer rates (from 4 to 2.3 percent). Sixty-seven percent of nursing home facilities achieved a high to medium level of implementation. Factors associated with high and medium levels of implementation were a designated project lead committed to making On-Time implementation a priority, interest in building skills of the frontline (including CNA skills), multidisciplinary team participation and users, On-Time reports, and willingness to redesign clinical processes to integrate On-Time reports into daily or weekly workflow.
    • Reduction in pressure ulcer incidence: In an evaluation study in New York State, the implementation of the On-Time reports and associated process improvements was associated with a large and statistically significant reduction in pressure ulcer incidence compared with the incidence in comparison facilities that did not implement On-Time. Implementation of at least 3 of the 4 core reports was associated with a 57-percent reduction from the 4.6-percent baseline monthly incidence rate observed among our participating nursing homes to a 2.0-percent incidence rate, or approximately 2.6 pressure ulcers avoided per month per 100 residents.
  • Better, more complete CNA documentation:
    • Pilot study: Before the pilot project, CNAs used an average of 6.2 forms to document care; after implementation, this number was reduced to 2.9, a decline of more than 50 percent. On average, documentation completeness rates ranged from 80 to 90 percent at the start of the project; 6 months after use, they rose to (and stabilized at) approximately 95 percent.
    • Subsequent implementation: For the subsequent implementation, CNA documentation was streamlined, and CNA documentation completeness increased in all facilities.
  • Less overtime: A pre- and post-implementation analysis of staff feedback forms conducted as part of the pilot study revealed a reduction in the amount of overtime needed to complete documentation; the average proportion of staff reporting that they "sometimes or never" stayed late to complete documentation rose from 71 to 100 percent across all facilities, with corresponding declines in those reporting that they often stayed late to complete documentation.
  • Higher CNA satisfaction:
    • Pilot study: After pilot implementation, CNAs reported higher levels of job satisfaction and efficiency and better relationships and communication with nursing staff.
    • Subsequent implementation: After subsequent implementation of On-Time, communication among care team members improved, staff experience was positive, and time to compile reports for State regulators and the CMS minimum data set was reduced.
  • Confirmation of reduction in pressure ulcers and improvement in CNA documentation and satisfaction in new research: The New York State On-Time Quality Improvement in Long Term Care (On-Time) study, conducted from January 2008 through December 2009, was implemented to advance the strategic plan to disseminate the On-Time quality improvement results nationwide by (1) transferring knowledge of how to redesign workflow and clinical decision support from the Agency for Healthcare Research and Quality (AHRQ) On-Time Quality Improvement Program to nursing homes in New York and (2) testing whether this partnership achieves better pressure ulcer outcomes for 15 New York nursing homes. Information provided in September 2012 reveals the following results from a study of implementation in 12 nursing homes:
    • For three facilities completing On-Time implementation facility-wide in 2008 (after 9 months of implementation), the high-risk pressure ulcer quality measure declined by 30 percent (from 11.7 to 8.2 percent), the in-house pressure ulcer incidence declined 57 percent, and the weight loss quality measure declined 12.5 percent (from 5.3 to 4.7 percent).
    • For the 10 facilities that started by the fourth quarter of 2008, after 9 months of implementation, assessment indicated a 13 percent decline in the high-risk pressure ulcer quality measure (from 12.3 to 10.7 percent), and the weight loss quality measure declined 10 percent (from 7.5 to 6.7 percent). Two facilities that started in 2009 did not report data at this time. All 15 facilities fully implemented the On-Time program facility-wide by December 2009.
    • There were 38 units from 10 facilities assessed at 3 months post-implementation with a 33 percent decline in in-house pressure ulcer rates. There were 25 units from 8 facilities assessed at 6 months post-implementation with a 30 percent decline in in-house pressure ulcer rates. There were 12 units from 4 facilities assessed at 12 months post-implementation with a 50 percent decline in in-house pressure ulcer rates. For units achieving a high level of implementation, the results were greater: In-house pressure ulcer incidence declined by 58 percent, 64 percent, and 58 percent at 3, 6, and 12 months, respectively, post-implementation.
    • In all facilities, CNA documentation was streamlined, and completeness rates were maintained consistently at greater than 75 percent. All facilities reported that CNA satisfaction and team communication improved.
    • Twelve (80 percent) nursing home facilities achieved a high to medium level of implementation. Qualitative research revealed the following factors to be associated with a high and medium level of implementation:
      • The project leader at the implementing facility was a leader and decisionmaker at the facility; he or she collaborated closely with the project consultant to support team participation and ensure that On-Time activities were carried out.
      • A multidisciplinary team participated in 75 to 100 percent of team calls and implemented project activities across disciplines, as designed, to promote the use of report information for decisionmaking, team collaboration, and coordination of resident care.
      • The team adhered to a project plan for redesign and process improvement implementation.
      • The team expanded the On-Time approach beyond core interventions to include the use of clinical decision reports in other clinical areas, such as pain management review.

Evidence Rating (What is this?)

Moderate: The evidence consists of a prospective observational pilot study and subsequent implementation efforts allowing before-and-after comparisons of key clinical and process outcome measures, including pressure ulcer rates and documentation completeness and efficiency, as well as an evaluation study comparing pressure ulcer rate reductions in implementing and nonimplementing facilities in New York State.

How They Did It

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Planning and Development Process

Key On-Time steps in the planning and development process for pressure ulcer prevention included the following:
  • Establish a multidisciplinary team: Each participating facility established a multidisciplinary team to implement the project. The teams included clinical staff with in-depth knowledge of clinical operations, coordination of resident care, and direct resident care activities and processes: unit nurses, minimum data set nurses, wound nurses, dietitians, restorative or activities staff, CNAs, social workers, and staff educators.
  • Redesign CNA documentation: A project facilitator held biweekly calls lasting up to 1 hour with each team over a period of 6 to 9 months to redesign CNA daily documentation to include elements required for generation of On-Time CDS reports.
  • Pilot test redesigned CNA documentation: Each team pilot tested its new CNA documentation form on one to two nursing units for 2 to 4 weeks. The CNA documentation form was revised to incorporate feedback from actual CNA users and nurses participating in the pilot.
  • Design CDS reports for frontline staff: The multidisciplinary facility teams participated in conference calls and attended a 1.5-day working session with project facilitators to help design CDS reports that used CNA documentation of pressure ulcer risk elements to identify residents at highest risk of developing a pressure ulcer.
  • Develop implementation strategies for CDS report use: Each facility team worked with the project facilitator to identify practical strategies for incorporating clinical reports into clinical workflow such as weekly care planning with multiple disciplines.
  • Develop functional requirements for long-term care (LTC) health information technology: To increase the ability of LTC health information technology vendors to support the program for nursing home clients, the company team developed functional requirements for LTC health information technology that included the standardized CNA data elements and definitions of the five clinical reports.
  • Ensure new facility adoption: Because the program has been tested and proven successful, additional facilities can adopt the system—usually within 2 to 3 months if there is an existing LTC health information technology system in place—by following the steps outlined below:
    • Introductory On-Time meeting: Leadership at facilities interested in adopting the On-Time program attend an introductory meeting held by company project facilitators.
    • Documentation gap analysis: Facilities that decide to participate in On-Time send their current documentation forms to the project facilitator; the project facilitator examines the forms and reconciles them with standard data elements required for CDS reports. Facilitator and facility representatives (CNAs and other facility staff; e.g., nurses or the director of nursing and wound nurses) hold several conference calls (usually two 1-hour calls) to adapt their current documentation to include required data elements.
    • Collaboration with health information technology vendors/communication of software requirements: The facility and the project facilitator work with the vendor of the facility's choice; 10 vendors have been vetted by the company for their ability to produce the On-Time pressure ulcer prevention reports. The vendor then creates the software to produce the reports and works with the facility to implement health information technology. Alternatively, the template is incorporated into the facility’s existing electronic medical record (EMR) by facility information technology staff or by the EMR vendor.
    • Quality improvement process: Frontline teams participate in conference calls and working sessions to integrate reports into communication and care planning efforts.
  • Pressure ulcer healing implementation program development: The company formed a pressure ulcer healing collaborative with 10 clinical teams in 10 California long-term care facilities. Project participants were located in California, Ohio, and Pennsylvania and included facility teams familiar with On-Time and teams interested in learning more about On-Time. Key steps in the project are similar to the development of the On-Time Pressure Ulcer Prevention Module and included the following:
    • Redesign and standardize comprehensive wound assessment: A core set of wound elements was defined with input from a literature review, the pressure ulcer healing collaborative team, and pressure ulcer experts. Next, the core data elements confirmed by the collaborative data elements were standardized. Although many facilities had established formularies of wound care products, the collaborative agreed on a standardized list that could be used to document treatments across facilities.
    • Pilot test the redesigned wound assessment: A prototype of the redesigned wound assessment tool that included assessment elements and wound treatments was developed and tested by all facilities participating in the collaborative. Barbara Bates-Jensen, RN, PhD, a leading wound expert, facilitated the use of the new form at all collaborative facilities located in California.
    • Design CDS for clinicians: Prototype reports to support monitoring and management of pressure ulcers by facilities and nursing units were designed for collaborative team and wound expert review. Existing facility tools, reports, and processes used to monitor pressure ulcer healing were incorporated into the design of the new CDS reports. Reports were designed to provide a comprehensive view of ulcer status, including onset date, inhouse or acquired origin, duration of ulcer in days, etc. The CDS reports are generated from weekly wound assessment documentation and eliminate the former manual process to compile monthly wound data.
    • Develop implementation strategies for CDS report use: The collaborative provided input into the practical uses of CDS reports in day-to-day or weekly care reviews by wound nurses, dietitians, and leadership teams.
    • Develop functional requirements for long-term care HIT vendors: To increase the ability of long-term care HIT vendors to support the On-Time program for nursing home clients, the company team developed functional requirements for long-term care HIT that included the standardized wound assessment elements and definitions of the CDS reports.
    • Create education materials: The team developed education materials corresponding to (1) use of standardized documentation for weekly pressure ulcer assessment and treatments and (2) use of clinical decisionmaking reports. The materials were used by each team to orient nurses to the standardized documentation forms and clinical decisionmaking reports.
    • Review functional requirements with long-term care EMR vendors: The project facilitator worked directly with the EMR vendors interested in adding the module to their product by reviewing the functional specifications and assisting via conference call, when needed, to interpret or clarify the specifications.

Resources Used and Skills Needed

  • Health information technology: The resources for health information technology will depend on the type of technology the facility decides to implement or already has available to support On-Time modules and the amount IT support available to frontline staff.
  • Leadership support: Leadership endorsement for use of IT to support quality improvement initiatives affect the frontline staff ability to implement On-Time modules.
  • Core project team: A core group of facility clinical staff must have the time to participate in weekly team meetings for the first 1 to 2 months of implementation and then biweekly and monthly meetings to support ongoing implementation of the program; the core team members serve as champions of the program.
  • On-Time facilitator: An On-Time facilitator is required to work with each facility team during the initial implementation and then for at least 1 year afterward to ensure that process improvements and report use are integrated into clinical workflow, adopted by frontline staff, and sustainable.
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Funding Sources

Agency for Healthcare Research and Quality
The project was initially funded by AHRQ through the Partners For Quality program (AHRQ grant number: 5 U18 HS013696). Development of health information technology for the program was funded by a second AHRQ grant (Cooperative Agreement # 1 UC1 HS015350). Additional funding came from an AHRQ contract, HHSA29020050020C, to support dissemination into additional nursing homes with the addition of pressure ulcer healing data elements and reports. Support for health information technology came from the California Healthcare Foundation and other funders. Kinetic Concepts, Inc (KCI) funded pressure ulcer healing analyses.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Ensure leadership commitment and designate a clinical project leader: To facilitate implementation, an individual who is a champion of the program should be designated as project leader.
  • Obtain staff buy-in: CNAs and wound nurses may be reluctant to adopt a new documentation system, thinking that it will require more work. To get over this resistance, emphasize the efficiency benefits of the new system by highlighting quantitative and anecdotal data from prior adopters.
  • Solicit input from frontline staff: CNAs and wound nurses should be asked to review current documentation processes and highlight inefficiencies. They should also be involved in suggesting improvements to the template.
  • Assess quality improvement and health information technology readiness: Based on On-Time experience, it is important to assess nursing home readiness from a quality improvement and health information technology perspective. Readiness assessment can be found on the AHRQ On-Time Web site.
  • Consider On-Time facilitator training: One way to get started is to train a core group of facilitators who will be responsible for guiding the frontline team through implementation of On-Time quality improvement. Those interested in this training program may contact AHRQ or SLH Clinical Consulting.
  • Integrate reports into care: Develop concrete strategies and processes that leverage the information provided by reports to improve resident care and to contribute to multidisciplinary communication about care.
  • Establish a feedback process with CNAs and wound nurses: Ensure that CNAs and wound nurses are involved in understanding the use of the reports to enhance nursing care and their own role in ensuring care quality.

Sustaining This Innovation

  • Ongoing monitoring of report use by frontline staff: Keep track of report use—who is using the report, when is the report used, and what is the result of report review? Are report reviews resulting in new intervention or care plan updates?
  • Ongoing review of quality measures linked to each On-Time module: Conduct frequent reviews of quality indicators that should be affected because of report use.
  • Assign On-Time champion: Assign a member of frontline staff to serve as a champion of On-Time process improvements or consider multiple champions to take ownership of specific reports and process improvements. Ask the champions(s) to report periodically.

Use By Other Organizations

As of September 2011, the program has been implemented in more than 90 nursing homes in California, Arizona, Ohio, New York, Pennsylvania, Wisconsin, South Dakota, Michigan, North Carolina, and the District of Columbia; these facilities were assisted by On-Time project facilitators. Some On-Time programs have been implemented with support from Departments of Health in New York, California, and Washington, DC. Also, 10 long-term care health information technology vendors have included On-Time standard documentation data elements and clinical decisionmaking reports in their products. In addition, the On-Time quality improvement approach has been used as a foundation to design and implement other On-Time quality improvement modules, including falls prevention and avoidable transfers to hospitals and EDs.

More Information

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Contact the Innovator

Susan D. Horn, PhD
Senior Scientist
International Severity Information Systems, Inc.
Institute for Clinical Outcomes Research
699 E. South Temple, Suite 300
Salt Lake City, UT 84102
(801) 466-5595, x203
E-mail: shorn@isisicor.com

Sandra Hudak, MS, RN
Principal
SLH Clinical Consulting, Inc.
Austin, TX 78739
(512) 423-6353
E-mail: lhudak@slhclinicalconsulting.com

Innovator Disclosures

Dr. Horn and Ms. Hudak reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Hudak S, Sharkey S. Trendspotting: how IT triggers better care in nursing homes. An issue brief prepared for California Health Care Foundation. September 2011. Available at: http://www.chcf.org/publications/2011/09/trendspotting-it-nursing-homes.

Sharkey S, Hudak S, Horn SD, et al. Exploratory study of nursing home factors associated with successful implementation of clinical decision support tools for pressure ulcer prevention. Adv Skin Wound Care. 2013 Feb;26(2):83-92. [PubMed]

Horn SD, et al. Real-time optimal care plans for nursing home QI. Final report to AHRQ. December 31, 2007. Report provided by innovator.

Horn SD, et al. On-time prevention of pressure ulcers: partnering with quality improvement organizations. Final Report. December 31, 2007. Report provided by innovator.

Horn SD, et al. Nursing home IT: optimal medication and care delivery. Final report to AHRQ. March 11, 2008. Report provided by innovator.

Horn SD, et al. On-time pressure ulcer healing: partnering with quality improvement organizations. Final report to AHRQ. December 31, 2008 (revised March 13, 2009). Report provided by innovator.

Horn SD, Sharkey SS, Hudak S, et al. Pressure ulcer prevention in nursing homes: a pilot study implementing standardized nurse aide documentation and feedback reports. Adv Skin Wound Care. 2010;23(3):120-31. [PubMed]

Hudak S, Sharkey SS, Engleman M, et al. Pressure ulcer plan is working. Provider. 2008;34(5):34-9. [PubMed]

Sharkey S, Hudak S, Horn SD, et al. Leveraging certified nursing assistant documentation and knowledge to improve clinical decision making: the on-time quality improvement program to prevent pressure ulcers. Adv Skin Wound Care. 2011;24(4):182-4. [PubMed]

Sharkey S, Hudak S, Horn, S. On-time quality improvement manual for long-term care facilities. AHRQ Publication No. 11-0028-EF (January 2011). Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://www.ahrq.gov/ontimeqimanual.

Footnotes

1 Pressure ulcers. Washington, DC: American Association of Homes and Services for the Aging; April 27, 2007.
2 Annual nursing home expenses increased by 150 percent from 1987 to 1996. Press Release. Rockville, MD: Agency for Healthcare Research and Quality; 2001.
3 Miller H, Delozier J. Cost implications of the Pressure Ulcer Treatment Guideline. A report to the Agency for Health Policy and Research, Panel for the Treatment of Pressure Ulcers; August 1994.
4 Interview with Susan D. Horn, PhD, June 25, 2008.
5 Horn SD, Sharkey SS, Hudak S, et al. Pressure ulcer prevention in long-term-care facilities: a pilot study implementing standardized nurse aide documentation and feedback reports. Adv Skin Wound Care. 2010;23(3):120-31. [PubMed]
6 Sharkey S, Hudak S, Horn SD, et al. Leveraging certified nursing assistant documentation and knowledge to improve clinical decision making: the on-time quality improvement program to prevent pressure ulcers. Adv Skin Wound Care. 2011;24(4):182-4. [PubMed]
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Original publication: November 20, 2008.
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Last updated: December 18, 2013.
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Date verified by innovator: December 11, 2013.
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