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Service Delivery Innovation Profile

Enhanced Toileting Program Reduces Incontinence and Its Comorbidities Among Residents of Long-Term Care Facility

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A long-term care facility adopted an enhanced toileting program consisting of the following components: individualized toileting plan of care based on periodic resident assessments, revised and new care documentation tools, devices to assist with toileting, and comprehensive education and training for facility staff. The program led to a sharp decline in the prevalence of incontinence (from 76 to 31 percent of residents) and in associated comorbidities and staff injuries.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation data on key indicators, including the prevalence of incontinence, falls, pressure ulcers, staff injuries, and comorbidities.
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Developing Organizations

Sea View Hospital Rehabilitation Center and Home
Staten Island, NYend do

Date First Implemented

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Patient Population

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

Problem Addressed

Incontinence is a prevalent and often correctable condition that is associated with a significant clinical and economic burden. Consequences of incontinence include lower quality of life for residents, higher care costs, and greater incidence of incontinence-related comorbidities, such as pressure ulcers and falls.
  • High prevalence in long-term care facilities: More than one-half of residents in long-term care facilities have some type of incontinence.1 In the first quarter of 2003, the prevalence of incontinence at Sea View Hospital Rehabilitation Center and Home was 79 percent (39 percent above state and national averages).
  • Consequences and costs of incontinence: Incontinence can lead to a loss of self-esteem, reduced quality of life, patient falls, pressure ulcers, and staff injuries that occur while toileting residents. The annual costs of incontinence in the United States is estimated to be $8.5 billion.1
  • Potential for improvement: Approximately 30 percent of cases of incontinence can be corrected with appropriate diagnosis and aggressive treatment.2

What They Did

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Description of the Innovative Activity

Sea View Hospital Rehabilitation Center and Home developed an enhanced toileting program that consists of an individualized toileting care plan for each resident based on periodic, careful assessments; the use of new care documentation tools and a standing lift to facilitate toileting; and comprehensive education and training for facility staff. Key elements include the following:
  • Resident incontinence assessment: Nurses perform a detailed assessment at admission/readmission and on a quarterly basis, with additional assessments conducted if there are significant changes in the resident's bowel and bladder function. (Previously, assessments were conducted only on a quarterly basis.) The nurse uses an evaluation form that includes the patient name and room number; diagnoses; history of conditions that contribute to incontinence (e.g., prostate problems, constipation, and urinary tract infection); medications; mental status; mobility limitations; and frequency, type, and circumstances of incontinence. The nurse completes the form, notes his or her recommendations, and reviews it with the physician, prompting consideration of anticholinergic medication, use of a toileting program, or other interventions. The physician signs the form to confirm that they are in agreement with the assessment and treatment plan. The results of this assessment help the nurses define the resident's type of incontinence and inform the creation of the individualized toileting care plan, described below.
  • Individualized toileting care plan: Previously, a generic care plan ("toilet the resident every 2 to 4 hours") was included in every incontinent resident's plan of care. Now, the plan of care includes an individualized statement specifying the toileting schedule for that resident (e.g., toilet the resident at 8 a.m., 2 p.m., 4 p.m., and 8 p.m.) based on the incontinence assessment. Nurses investigate each case in which a resident does not have an individual plan to confirm that there is a valid reason for the lack of a plan (e.g., the resident has dementia or has contraindications to anticholinergic medications).
  • Enhanced documentation tools: Two tools were created or enhanced to facilitate the ability of staff members to adhere to the individual incontinence plan. These include the following:
    • Assignment card: The assignment card summarizes the resident's pattern of incontinence as identified on the assessment evaluation form and outlines a plan for when the resident should be toileted based on this pattern. The nurses complete the assessment cards and give them to the patient care technicians, who refer to the cards when providing patient care.
    • Activities of daily living (ADL) accountability sheet: The ADL accountability sheet was amended to include an incontinence section with the patient's individual toileting schedule. The sheet allows nurses to check off the type of care required by the resident; the patient care technician then initials the sheet to document that the care was provided and whether or not toileting was successful. Nurses and physicians review the accountability sheet to determine necessary modifications in care. Nurses sign the sheet at the end of the month to confirm their review.
  • Toilet-assist technology: The Standing and Raising Aid Lifts (standing lifts to facilitate patient transfers between beds or wheelchairs and toilets, with safety devices to prevent falls) are used to enhance patient comfort with toileting and to reduce the risk of caregiver injury.
  • Enhanced caregiver education: Formalized clinician education and training are provided periodically, including the following:
    • Incontinence education: A 2-hour, facility-wide inservice training session is held at least annually, led by a nurse educator who teaches nurses and patient care technicians about incontinence and toileting, including facility policies and procedures and the appropriate use of documents. Topics covered include detailed information on urinary and bowel incontinence; causes of incontinence; types of incontinence; differentiating symptoms; available treatments; individualized care planning; and consequences of incontinence, including pressure ulcers and falls. Ongoing, individualized education is provided to new staff and to existing staff members who need it.
    • Coding education: The facility's Minimum Data Set (MDS) assessment coordinators conduct an annual 2-hour education session for all nurses who are responsible for MDS coding and documentation to increase accuracy and reduce discrepancies. Ongoing, individualized education is provided both to new staff members, and to existing staff members if needed.
  • Ongoing monitoring: The program is monitored through biweekly chart audits, monthly interdisciplinary team unit rounds during which resident needs are discussed, and staff competency evaluations regarding use of the standing lifts and documentation forms.

Context of the Innovation

Sea View Hospital Rehabilitation Center and Home is a 304-bed long-term care facility located in Staten Island, NY. The organization is part of New York City Health and Hospital Corporation, the largest public health care system in the United States. The program was developed in response to a March 2003 staff review of the facility's performance on two MDS incontinence indicators. As mentioned previously, this review found that the facility's rate on one of the indicators ("prevalence of occasional or frequent bowel or bladder incontinence without a toileting plan") was well above state and national averages.

Did It Work?

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The program led to a sharp decline in the prevalence of incontinence, associated comorbidities, and staff injuries. Detailed results are as follows:
  • Less incontinence: The prevalence of incontinence decreased from 76 percent of residents during the third quarter of 2004 to 36.2 percent during the fourth quarter of that year; the rate has held steady at roughly 38 percent since that time. In the third quarter of 2004 (before program implementation), 63.2 percent of residents (86 of 136 residents) were triggered for occasional or frequent incontinence on the facility's MDS quality indicator report. By the first quarter of 2005, that figure fell to 31.8 percent (41 of 129 residents), before drifting up slightly to an average of 37.8 percent in 2007 (45 of 119 residents). In 2009, the prevalence of occasional or frequent bladder or bowel incontinence without a toileting plan further decreased to 31 percent. In 2012, residents who had frequent/occasional incontinence fluctuated each quarter between the low 30th to low 40th percentile (updated February 2013).
  • Fewer incontinence-related comorbidities: The prevalence of comorbidities associated with incontinence has also declined, as follows:
    • Falls: Historically, incidence of falls at Sea View is highest in residents' rooms, usually occurring when residents are on their way to the bathroom or in the bathroom. Implementation of an individualized toileting schedule has markedly improved the fall rate. The rate of falls fell from 8.345 falls per 1,000 patient days in 2003 to 6.1 per 1,000 patient days in 2006. In 2012, the number of resident falls dropped to an all-time low of 2 per 1,000 patient-days (0.2 percent) (updated February 2013).
    • Pressure ulcers: The rate of pressure ulcers decreased from 12.4 percent in 2003 to 7.27 percent in 2006. Information provided in February 2013 indicates that in 2012, this rate fell to 4 percent, which includes residents admitted from the hospital; the nosocomial pressure ulcer rate remains at less than 1 percent as of February 2013.
    • Fewer staff injuries due to toileting: The prevalence of back injuries among staff during toileting of residents fell from 5 to 1 percent between 2003 and 2006; this rate remained at 1 percent in 2012 (updated February 2013).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation data on key indicators, including the prevalence of incontinence, falls, pressure ulcers, staff injuries, and comorbidities.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Creation of multidisciplinary team: The team, which was led by the associate director of nursing, included nurses; patient care technicians; and the directors of medicine, nursing, pharmacy, rehabilitation, care management, and food services.
  • Failure mode and effects analysis: This performance improvement tool is used to identify specific failures in a process. The analysis identified seven failures that contributed to excessively high rates of incontinence at the facility; each failure was rated in terms of its frequency or likelihood of occurrence. The team also identified an action plan to address each failure (which are listed below).
    • Incomplete incontinence assessment of residents
    • Lack of criteria to identify residents who are candidates for a toileting program
    • Lack of resident reassessment for incontinence
    • Lack of a resident-specific toileting schedule or an individualized care plan
    • MDS miscoding
    • Knowledge deficits among clinical staff
    • Need for equipment to facilitate resident lifting during toileting
  • Literature review: The team performed an extensive literature review that contributed to the development of the evaluation form.
  • Development of program elements: The team designed elements of the enhanced program including changing the policy to call for an individualized care plan and periodic assessments, creating the evaluation form, creating and revising the documentation forms (assignment card and ADL accountability sheet), and designing processes to ensure implementation of these elements.
  • Identification of technology: Based on patient care technician concerns about difficulties encountered when toileting residents, the team researched equipment that could help and identified the Standing and Raising Aid Lift.
  • Obtaining senior leadership approval: Failure mode and effects analysis findings and the team's proposed changes were presented to the facility's Performance Improvement Committee, which approved the changes and authorized the purchase of one standing lift. After receiving positive feedback on the new technology, the committee approved the purchase of seven additional standing lifts (one for each unit).
  • Initial training: Initial training was performed for staff regarding the incontinence program and appropriate MDS coding.
  • Introduction to residents: Residents with adequate cognitive function were told about their incontinence care plan and were introduced to the standing lift technology.

Resources Used and Skills Needed

  • Staffing: The project was implemented with existing staff, who incorporated the development of the program and/or training into their daily activities.
  • Costs: Eight standing lifts were purchased at a total cost of $23,576.
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Funding Sources

Sea View Hospital Rehabilitation Center and Home
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Adoption Considerations

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Getting Started with This Innovation

  • Perform a formal analysis: A formal analysis is required to pinpoint the specific areas that need improvement and to ensure that solutions address these areas.
  • Obtain employee buy-in: Frontline staff members must support the initiative for it to work. Involving staff members in the redesign process can help to achieve buy-in.
  • Create a multidisciplinary team: Include staff members from various disciplines so that different perspectives can be incorporated into the new process. Choose team members who are positive and excited about their work.

Sustaining This Innovation

  • Monitor the staff on an ongoing basis: Monitor the staff and provide additional education regarding patient assessment, documentation, and MDS coding, as necessary.
  • Expect initial mistakes and do not get discouraged: Expect that documentation forms will not always be completed appropriately. Recognize that some employees are resistant to change, and continue to emphasize the reasons for the new policy to these individuals.

Additional Considerations

  • The enhanced toileting program does not apply to residents who are totally incontinent, including those for whom anticholinergics are contraindicated and those with cognitive impairment that prevents their ability to recognize the need to void.

More Information

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Contact the Innovator

Nancy Endozo, RN, BSN
Director of Nursing
Sea View Hospital Rehabilitation Center and Home
460 Brielle Avenue
Staten Island, NY 10314
(718) 317-3612

Innovator Disclosures

Ms. Endozo has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Morgan C, Endozoa N, Paradiso C, et al. Enhanced toileting program decreases incontinence in long term care. Jt Comm J Qual Patient Saf. 2008;34(4):206-8. [PubMed]


1 Morgan C, Endozoa N, Paradiso C, et al. Enhanced toileting program decreases incontinence in long term care. Jt Comm J Qual Patient Saf. 2008;34(4):206-8. [PubMed]
2 Fantl JA, Newman DK, Colling J, et al. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guidelines; March 1996.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: October 27, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 26, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.