Problem Addressed

• 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

Description of the Innovative Activity

• 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 decisionmaking 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 pressure ulcer risk status. 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 abnormal behavior, including biting, scratching, wandering, etc. The nurses and social workers can use this report during their assessments.
  • 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.
  • 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.
• Pressure Ulcer Healing Improvement Program: 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 documentation, develop weekly reports to support nurses’ clinical decisionmaking related to pressure ulcer treatment, and embed quality improvement changes in daily work routines to link efficiency and effectiveness in the care delivery process with sustainable improvement in resident pressure ulcer outcomes. 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 Program: Information provided in September 2012 indicates that the On-Time program has been expanded to other clinical areas. The goals of the On-Time Falls Prevention Program are to (1) collaborate with nursing home clinical staff to design clinical decision support tools, (2) develop implementation strategies 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, and designing standard 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. The falls quality improvement monitor reports are a set of management tools that provide monthly trended information for falls on each nursing unit.
• On-Time prevention of avoidable hospitalizations and emergency department (ED) visits: Information provided in September 2012 indicates that 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 On-Time Pressure Ulcer Prevention Program. Key elements of the program are similar to other On-Time components, such as using a bottom-up approach, agreeing on standardized data elements (including nursing, CNA, social worker, and physician documentation) related to hospital and ED risk assessment, and designing standard reports to help the care planning team identify residents at risk for transfer to hospital or ED, track changes in resident risk profile, and support root cause analyses 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 risk for transfer to hospital or ED earlier than other tools (e.g., minimum data set). The transfer risk reports enable teams to be proactive and consistent in identifying residents at high risk on a weekly basis. 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 are three management tools that provide monthly and trended information on transfers to hospital and ED by facility or nursing unit. A variety of report views are provided, such as monthly and quarterly periods for facility and unit level reports. Specifically, the quality improvement monitor reports help to (1) identify trends and patterns by nursing unit or facility and target followup with staff, provide educational in-services as needed, and develop new strategies to address residents at high risk for transfer; (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, stimulate timely interventions, and identify need for programmatic changes.

References/Related Articles

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Innovator Disclosures

Results

• Fewer pressure ulcers:
  • Pilot study: The pilot prospective observational study 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, various team members using On-Time reports, and process redesign to integrate On-Time reports into existing meetings and implement new processes, such as 5-minute standup meetings with dietary staff and CNAs.
  • Reduction in pressure ulcer incidence: Information provided in September 2012 indicates that in a recent 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 nonimplementing facilities. Implementation of the four 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 was a clinical operations decisionmaker who closely collaborated with the project consultant to support team participation and confirm that On-Time activities were carried out.
    • A multidisciplinary team participated in 75 to 100 percent of team calls and delegated responsibilities to members of the team.
    • 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 other areas of clinical process improvement.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Establish a multidisciplinary team: Each participating facility established a multidisciplinary team to implement the project. The teams included unit nurses, minimum data set nurses, wound nurses, dietary staff, restorative or activities staff, CNAs, social workers, and staff educators.
• Redesign documentation elements: A project facilitator held biweekly calls lasting 30 to 45 minutes with each team over a period of 6 to 9 months. The teams redesigned the documentation process, beginning with a template that included required data elements for clinical decisionmaking reports.
• Pilot test redesigned documentation: Each team pilot tested its new documentation form by asking CNAs to use the forms on units for approximately 2 to 4 weeks. The template was revised based on CNA and wound nurse suggestions.
• Develop clinical reports: The teams participated in conference calls and a 1.5-day working session with company project facilitators to draft and finalize reports that monitored CNA documentation of key elements and identified high-risk residents.
• Incorporate reports into daily work: Each facility team worked with the project facilitator to incorporate clinical reports into weekly care planning and treatment and to share learning with other participants.
• Develop requirements for electronic systems: To increase the ability of health information technology vendors to support the program for nursing home clients, the company team developed functional requirements 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, by following the steps outlined below:
  • Introductory meeting: New facilities that are interested in adopting the On-Time program attend an introductory meeting held by company project facilitators.
  • Documentation gap analysis: Facilities that decide to participate 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 partnered with clinical teams from 10 California nursing homes (which had also partnered with the company in two previous projects) to form a pressure ulcer healing learning collaborative. Key steps in the project included.
  • Develop standardized data elements: A core set of pressure ulcer healing standardized data elements was developed with input from a literature review and pressure ulcer experts. Next, the core data elements were reviewed with facility clinical teams to finalize standardized data elements collected by all facilities related to wound assessment and treatments.
  • Develop prototype documentation forms for pressure ulcer wound assessment, risk assessment, and treatments: In preparation for collaborative work with all facilities, the collaborative reviewed each facility’s existing forms for documenting weekly skin and wound assessment by nurses. The collaborative compared data elements on each facility’s existing documentation with the preliminary core list of standardized data elements and established a process to support collaboration with the facility implementation team. The team incorporated literature findings, the most recent CMS documentation requirements, and facility-specific protocols into the standardized list of elements. For pressure ulcer treatments, the project team considered suggestions from consultants and defined a core set of standardized data elements to capture details of pressure ulcer treatments. Although many facilities had established formularies of wound care products, a standardized list was created that could be used to document treatments across facilities.
  • Design reports for clinical decisionmaking related to pressure ulcer healing: Working with facility implementation teams, the project team designed prototype reports for timely monitoring and clinical decisionmaking related to pressure ulcer healing. Existing facility tools, reports, and processes used to monitor pressure ulcer healing were reviewed and used to draft initial ideas for clinical reports. The pressure ulcer healing reports included standardized wound assessment and treatment data elements. Reports were designed to provide a comprehensive review of ulcer status, including duration of ulcer, treatments in place, detailed wound description, and healing progress. The goal was twofold: to streamline information reporting by eliminating manual compilation each month by the nurses and to compile information to support improved clinical decisions and monitoring.
  • 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.
  • Coordinate development and installation of information technology modules for pressure ulcer healing clinical data capture and reporting: In coordination with each facility’s health information technology vendor, the team facilitated the development and installation of a pressure ulcer healing health information technology module at participating facilities. The team worked with vendors to develop or adapt an electronic decision support system that captured data from standardized clinical documentation forms, stored information in a database, and supported feedback to facilities in timely standard reports developed in this project. Project facilitators communicated requirements for pressure ulcer assessment, treatment documentation, resident risk factors, and clinical report specifications to the health information technology vendors. In addition to providing the materials, project facilitators held numerous conference calls with health information technology vendor developers to clarify requirements and answer questions. Three vendors have been vetted by the company for their ability to include pressure ulcer healing data elements and reports.

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 for CNA electronic documentation and the quality improvement experience and skills the staff has available for this program. These factors will determine the amount of facilitative help the facility needs and the resources available internally to do the work.
• Staffing: A core group of facility clinical staff must invest their time by participating in weekly team meetings—usually for the first 2 to 3 months and then biweekly and monthly meetings thereafter—to integrate standardized data elements into CNA and wound nurse documentation forms, redesign workflow, and integrate clinical reports into daily work processes. An On-Time facilitator works with each facility team during the initial implementation.
• Skills needed: Staff require a combination of the following skills and experience to facilitate program implementation:
  • Project management: To oversee the project, develop and manage the work plan, and establish plans for impact monitoring data collection and reporting.
  • Process improvement: To facilitate the team’s implementation of On-Time process improvements.
  • Clinical informatics: To coordinate information needs between the facility and health information technology vendor.

Funding Sources

Getting Started with This Innovation

• Ensure leadership commitment, and designate a clinical project leader: Leaders should be committed to supporting the streamlined documentation process, incorporating report data into staff meetings, and adopting new care processes based on care reports. To facilitate implementation, an individual (director of nursing or clinical nursing designee) 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 (updated July 2011).
• 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. Contact AHRQ or Health Management Strategies if you are interested in this training program (updated July 2011).
• 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

• Continually monitor results: Produce and consult reports on an ongoing basis, using them to identify and analyze trends in the quality of nursing home care.
• Continually monitor documentation processes: Verify that data are entered onto the forms accurately and that CNA and wound nurse educational needs related to documentation are addressed as they arise. These steps will build confidence in the accuracy of the reports.
• Train new staff on documentation: Ensure that training materials for using the standardized documentation form are incorporated into staff orientation procedures.

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