On-Time Overview

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

On-Time is a program that reengineers nursing home workflow processes around improving clinical outcomes and integrates health information technology (Health IT) and clinical report information into those processes.  The program incorporates culture change, workflow redesign principles, and current best practices and provides specific tools and process improvements to caregivers in nursing homes.

This section answers the following questions:

  • Why should a long-term care facility be interested in the On-Time program?
  • What are the guiding principles used to develop On-Time?
  • What are the On-Time tools?
  • What is the On-Time implementation process?

On-Time Results to Date

Participating facilities have found many positive effects of the On-Time program. On a broad scale, On-Time has:

  • Improved clinical outcomes (pressure ulcer rates).
  • Increased Certified Nursing Assistant (CNA) engagement in process improvement.
  • Improved communication about high-risk residents among the entire care team.
  • Improved prevention practices and timely interventions for high-risk residents. 

Results to date follow:

  • Reduced in-house incidence of pressure ulcers:
    • Forty-three percent decline (from 4 percent to 2.3 percent) based on initial implementation of program with 21 facilities with high level of implementation.
    • Fifty-five percent decline 12-months postimplementation based on New York State On-Time early results for the rapid implementers (n=3 facilities).
  • Reduced number of high risk residents with pressure ulcers (Centers for Medicare & Medicaid quality measure):
    • One-third reduction within a year based on pilot program among 11 participating nursing homes.
    • Decline of 30.5 percent (from 13.1 percent to 9.1 percent) based on initial implementation of program with 21 facilities with a high level of implementation.
    • Decline of 30 percent (from 11.7 percent to 8.2 percent) 9-months postimplementation  based on New York State On-Time early results for the rapid implementers (n=3 facilities).
  • Increased engagement of CNA clinical care staff in On-Time process improvements:
    • "CNAs are enthusiastic about On-Time processes and really feel like part of the team now."—Director of Nursing
    • "Reviewing the reports with dietitian, nurse, and other CNAs is very helpful.  We have a lot of information to share.  We feel like we are being listened too."—CNA
  • Earlier and more consistent identification of high- risk residents:
    • CNAs are clearly identifying residents who are declining.  They are picking up on residents who can't feed themselves, not eating; anything they see that is different is being reported."—Nurse Manager
  • Improved communication among entire multidisciplinary team:
    • CNAs are more comfortable approaching dietitians throughout the day to communicate issues."—Dietitian
  • Sustained process Improvements:
    • The On-Time approach has helped our pressure ulcer prevention become part of everyday practice."—Director of Nursing

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On-Time Guiding Principles

The set of principles used as a foundation for developing the On-Time program are:

  • Multidisciplinary teams are essential for quality improvement (QI) efforts.
  • CNAs are critical members of the multidisciplinary team and can be better used in QI efforts with a clear role and well-structured process.
  • QI efforts integrated into daily work are more readily adopted and sustained.
  • Health IT alone will not lead to improved quality.  Use of Health IT for improved clinical decisionmaking requires redesign of workflow and links to specific process improvement activities.
  • Tracking tools help teams monitor progress.

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On-Time Tools

The On-Time tools are organized into four categories:

  1. Set of CNA documentation data elements developed and refined by more than 50 facilities to standardize and streamline CNA documentation processes and incorporate key measures of clinical best practices for CNA and care team use.
  2. Clinical decisionmaking reports (On-Time reports) that are viewed weekly and contain trended information using daily CNA data: (1) Completeness Report for CNA documentation, (2) Nutrition Report, (3) Weight Summary Report, (4) Trigger Summary Report that identifies residents at high risk for pressure ulcer formation, (5) Priority Report that provides an overall summary of changes in resident clinical status from previous week, and (6) Red Area Report that identifies residents with red areas on the skin.
  3. Process improvements linked to use of each On-Time report.
  4. Tracking Tools to monitor progress of implementation strategies.  Tracking tools are available for each On-Time report and demonstrate effectiveness of process improvement efforts.

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On-Time Implementation Process

On-Time implementation is a 15- to 24-month facilitated QI program that is then embedded in ongoing practice.  On-Time implementation has five phases:

  1. Health IT and On-Time Program setup: Includes completing action items related to Health IT (if necessary), identifying staff and facilitator resources, establishing the workplan, and developing a plan for measuring impact.
  2. Documentation review and redesign: Focuses on review of CNA documentation data elements and process redesign.
  3. Process improvement implementation: Involves the facility team working with a facilitator to implement On-Time reports and process improvements on all units.
  4. Impact monitoring: Includes gathering and reporting impact data at baseline (preimplementation) and every 6 months.
  5. Program maintenance: Includes plans to sustain process improvements as part of ongoing operations.

Minimal requirements for successful implementation follow:

  • An engaged project management nursing team that includes Director of Nursing (DON) or Assistant DON, staff development, and quality improvement staff.
  • Multidisciplinary clinical team participation that include CNAs, nurses, dietitians, rehabilitation therapists or restorative nurses, and social work staff.
  • Health IT for CNA daily documentation that meets On-Time requirements, including standardized CNA documentation elements.
  • Redesigned key CNA documentation processes.
  • Implementation of at least four On-Time process improvements (described in subsequent sections).
  • Established procedure for monitoring impact and providing feedback to frontline team members.
  • Facilitator/consultant who facilitates the implementation process and serves as a resource to the facility team and Health IT vendor.

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Where To Learn More About On-Time

A short streaming video that includes discussions about On-Time from staff at three pilot facilities in Wisconsin, California, and Arizona is available at: http://www.ahrq.gov/research/ontime.htm.

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Articles on pressure ulcer prevention in long-term care facilities include:

  • 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.
  • Hudak S, Sharkey SS, Engleman M, et al. Pressure ulcer plan is working. Provider 2008 May;34(5):34-9.
  • Hudak S, Sharkey SS. Health information technology: are long term care providers ready? San Francisco: California HealthCare Foundation; April 2007.

Key references of clinical evidence supporting strategies used to develop the On-Time tools include:

  • Pressure Ulcer Guideline Panel. Pressure ulcers in adults: prediction and prevention. Guideline Report No. 3. Rockville, MD: Agency for Health Care Policy and Research; 1993. AHCPR Publication No. 93-0013.
  • Clinical Practice Guideline: Pressure ulcers. Columbia, MD: AMDA; no date. Product Code CPG2-12. Available at: http://www.amda.com/tools/cpg/pressureulcer.cfm.
  • Brandeis GH, Ooi WL, Hossain M, et al. A longitudinal study of risk factors associated with the formation of pressure ulcers in nursing homes. J Am Geriatr Soc 1994;42:388-93.
  • Ek AC, Unosson M, Larrson J, et al. The development and healing of pressure sores related to the nutritional state. Clinical Nutr 1991;10:245-50.
  • Breslow RA, Bergstrom N. Nutritional prediction of pressure ulcers. J Am Diet Assoc 1994;94:1301-6.
  • Gilmore SA, Robinson G, Posthauer ME, et al. Clinical indicators associated with unintentional weight loss and pressure ulcers in elderly residents of nursing facilities. J Am Diet Assoc 1995;984-92.
  • Lyder CH. Pressure ulcer prevention and management. JAMA 2003;289:223-6.
  • Saliba D, Rubenstein LV, Simon B, et al. Adherence to pressure ulcer prevention guidelines: implications for nursing home quality. J Am Geriatr Soc 2003;51:56-62.
  • Berlowitz DR, Young GJ, Hickey EC, et al. Quality improvement implementation in the nursing home. Health Serv Res 2003;38(1 Pt 1):65-83.
Page last reviewed January 2011
Internet Citation: On-Time Overview: On-Time Quality Improvement Manual for Long-Term Care Facilities. January 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/ontimeqimanual/qimanual2.html