Purpose: The purpose of the project "On-Time Quality Improvement in Long Term Care" (On-Time), developed by the Agency for Healthcare Research and Quality (AHRQ) with support from the California Health Care Foundation (CHCF), was to reengineer the nursing home's workflow processes around pressure ulcer (PrU) prevention and integrate health information technology into those processes. The project was designed to bridge the gap between staff knowledge and staff practice, to facilitate good and consistent preventive care practices, and to target resources to those at high risk of developing PrUs.
Scope: We partnered with four Quality Improvement Organizations (QIOs) and 21 nursing homes (approximately 2,500 beds) to implement an evidence-based practice quality change strategy developed in the "Real Time Optimal Care Plans for Nursing Home QI" grant (U18 HS13696) ("Real-Time") funded by AHRQ.
Methods: The project team, working with QIO partners and provider facilities, used a process established in "Real-Time" to redesign workflow quickly (rapid cycle improvement) and adopt process change. On-Time implementation incorporated:
- Core data elements developed and refined over a 2-year period by 11 pilot facilities to streamline documentation processes and incorporate key measures of quality for certified nursing assistant (CNA), wound nurse, and Care Team use.
- Feedback reports for improved care planning and clinical decisionmaking. Five weekly reports were created using CNA data:
Each report displayed resident-specific information for each unit.
- Completeness report for CNA documentation.
- Nutrition report.
- Behavior report.
- "Trigger" report that identified residents at high risk of pressure ulcer (PrU) formation.
- Priority report that provided an overall summary.
- Clinical workflow redesign strategies that improved operational efficiencies, improved communication among clinical team members, and reduced PrU incidence.
Results: Results were achieved in clinical outcomes, workflow efficiencies, and staff experience. Overall, there was a 13 percent reduction in the Centers for Medicare & Medicaid Services (CMS) high-risk PrU quality measure 6 months postimplementation. Facilities with a high level of implementation had a 30.5 percent decline (from 13.1% to 9.1%) in the PrU quality measure and a 42.5 percent decline in in-house PrU rates (from 4% to 2.3%).
In all facilities, CNA documentation was streamlined and CNA documentation completeness increased. One-third (67%) of nursing homes achieved a high to medium level of implementation. In these facilities, 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.
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 the skills of front-line staff (including CNAs), multidisciplinary team participation, various team members using the On-Time reports, and process redesign to integrate On-Time reports into existing meetings and implement new processes, such as a 5-minute stand-up meeting with dietary staff and CNAs.
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