On-Time Quality Improvement Manual for Long-Term Care Facilities

The On-Time Quality Improvement Program is a practical approach to quality improvement (QI) in long-term care, embedding QI strategies and best practices into health information technology (Health IT). The On-Time QI for Long-Term Care Program (On-Time) was developed with funding from the Federal Agency for Healthcare Research and Quality (AHRQ), in collaboration with the California Health Care Foundation (CHCF), New York Department of Health, California Department of Public Health, Quality Improvement Organizations (QIOs) in the District of Columbia and California, and more than 75 nursing homes across the United States.

On-Time focuses on:

  • Leveraging the documentation and knowledge of Certified Nursing Assistant (CNA) staff, who serve as primary informants to licensed staff.
  • Supporting clinical decisionmaking based on best practice guidelines through use of Health IT in routine practice.
  • Establishing practices for proactive risk identification and early intervention as part of frontline caregivers' daily work.
  • Providing ongoing feedback on process and outcomes to frontline teams.

While pressure ulcer prevention is the initial clinical area of focus, AHRQ is applying the On-Time approach to other clinical areas, such as falls prevention and management, pressure ulcer healing, and prevention of emergency department and inpatient hospital transfers.

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Challenges of Improving Pressure Ulcer Prevention Practices in Nursing Homes

Pressure ulcer incidence and prevalence remain high among nursing home residents despite much effort to create and implement guidelines for prediction and prevention of ulcers (e.g., AHRQ guidelines on prevention and treatment of pressure ulcers, American Medical Directors' Association guidelines to prevent pressure ulcers). Pressure ulcers, defined as "any lesion caused by unrelieved pressure resulting in damage of underlying tissue," are a serious and common problem in frail and elderly adults.1 Pressure ulcers cause pain and disfigurement, interfere with activities of daily living, and are associated with longer hospital stays and increased rates of morbidity and mortality.2 In long-term care facilities, reported rates of pressure ulcer incidence range from 2.2 percent to 23.9 percent3 and prevalence rates range from 2.3 percent to 28 percent.4

Every year, pressure ulcers affect more than 1 million acute care and nursing home patients. More than $355 million is spent annually on pressure ulcer treatment in long-term care settings.2,3,5 The cost of pressure ulcers is high, projected between $1.3 billion and $6.8 billion,1,6,7 and ulcers have serious consequences: resident morbidity, mortality, and loss of quality of life. Additional costs are associated with liability and litigation. While the financial costs associated with pressure ulcers are high, the human toll of pain, depression, altered self-image, stress, infection, and increased morbidity and mortality is immeasurable.

Efforts focused on reducing pressure ulcer incidence are common. Despite knowledge about how to prevent pressure ulcers in nursing homes, rarely have improvement efforts integrated tools or resources needed to support implementation efforts into everyday practice within a nursing home. Too often, practice improvements are designed and implemented without thinking through how they will be integrated efficiently with existing staff workflow and documentation processes.

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Purpose of the On-Time QI Manual

This manual is an introduction to the On-Time QI approach. It provides an overview of the tools and process improvements and describes the implementation process. Target users are stakeholders interested in nursing home QI (e.g., departments of health, Quality Improvement Organizations), nursing home leaders responsible for deciding QI priorities, and nursing home personnel responsible for quality improvement. In each section, we highlight areas to note: On-Time tools, process improvement key action steps, implementation tips, and quotes from teams who have implemented On-Time.  

The On-Time Manual is organized as follows:

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1. Morris J, Lipsitz L, Murphy K, et al., eds. Quality care in the nursing home. St Louis: Mosby Lifeline; 1997.

2. 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. Rockville, MD: AHCPR; August 1994.

3. Cuddigan J, Ayello EA, Sussman C, eds. Pressure ulcers in America. Prevalence, incidence, and implications for the future. Reston, VA: National Pressure Ulcer Advisory Panel; 2001.

4. Coleman EA, Martau JM, Lin MK, et al. Pressure ulcer prevalence in long-term nursing home residents since the implementation of OBRA '87. Omnibus Budget Reconciliation Act. J Am Geriatr Soc 2002;50:728-32.

5. Berlowitz DR, Brandeis GH, Anderson J, et al. Effect of pressure ulcers on the survival of long-term care residents. J Gerontol A Biol Sci Med Sci 1997;52A:106-10.

6. Horn SD, Bender SA, Bergstrom N, et al. Description of the National Pressure Ulcer Long-Term Care Study. J Am Geriatr Soc 2002;50:1816-25.

7. Horn SD, Bender SA, Ferguson ML, et al. The National Pressure Ulcer Long-Term Care Study: pressure ulcer development in long-term care residents. J Am Geriatr Soc 2004;52:359-67.

Page last reviewed January 2011
Internet Citation: Introduction: On-Time Quality Improvement Manual for Long-Term Care Facilities. January 2011. Agency for Healthcare Research and Quality, Rockville, MD.