On-Time Implementation (continued)

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

Step 5: Implement Process Improvements Using the Priority Report

This section describes how to use the Priority Report and how a team can integrate the report into practice. The Priority Report is used to identify residents at risk for developing a pressure ulcer.

This section provides:

  • An orientation to the Priority Report.
  • Examples of process improvements that use information from the report to determine if further assessments or followup are needed.
  • Implementation tips from nursing homes that have integrated the Priority Report into daily or weekly practice.
  • Frequently asked questions about using the Priority Report.

Orientation to the Priority Report

The Priority 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.
  • 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. The report can assist the nurse in prioritizing residents who need further assessment to rule out a significant change in clinical condition. It also helps to prioritize discussions with team members to determine appropriate followup.


Residents with changes from the previous week in at least one of the five risk areas display on the Priority Report (Table 5.1). All documentation used in this report is derived from Certified Nursing Assistant (CNA) documentation except new or worsening pressure ulcer, which is obtained from nurse charting of wound assessments.

The Priority Report answers the following questions:

  • How many residents have documented changes from the previous week?
  • How many resident are at high nutritional risk (decreased meal intake AND weight loss)?
  • How many residents had an increase in urinary incontinence from the previous week?
  • How many residents had more than three behavior problems for the report week?

Process Improvements Using the Priority Report

The On-Time team integrates the use of the Priority Report into routine practice to help monitor changes in resident status and prioritize residents for team discussions.

Recommended steps follow:

  1. Assign a team member to review the report weekly.
  2. Review information from the current week and compare against the previous week.
  3. Identify residents for followup. Possible questions to ask members of the multidisciplinary team include:
    • Are report results consistent with resident's clinical picture? If not, why not? Is there a documentation issue?
    • Are nurses aware of potential changes in resident status? How many residents are new admissions? Does the report provide insights?
    • Do team members need to follow up? Confirm communication plan and next steps.
  4. Decide on best communication mechanism (e.g., shift report, 24-hour report, weekly meeting).
  5. Establish a plan to implement the process on all nursing units and agree to a timeline.

Examples of team members reviewing the Priority Report include:

  • Unit coordinator and dietitian review the Priority Report in conjunction with the Nutrition Report prior to 5-minute standup meetings to help focus on high-risk residents.
  • Nurse managers and MDS (Minimum Data Set) nurse use this report to identify residents with potential changes in health status, and flag residents to discuss at the morning meeting.
Frequently Asked Questions

Question: Our CNAs do not document information about ulcers. Where is the information on worsening and new ulcers coming from?

Answer: The worsening and new ulcer data come from nursing documentation.

Question: Is this a good report to have our social worker use?

Answer: Yes. Several On-Time teams indicated that the social worker found this report quite helpful to monitor residents' behaviors, have discussions with CNAs, and identify CNA inservice needs.

Question: We identify changes in resident status on a daily basis. How will this process add value to what we already do?

Answer: The Priority Report information flags changes in the past week. Often, trends or subtle changes are not picked up on review of information for the last 24 hours.

Question: Why are the Nutrition Report indicators, decrease in meal intake and weight loss, repeated on this report?

Answer: The indicators for high risk on the Nutrition Report are included on the Priority Report because this is a snapshot of key items across Nutrition, Trigger Summary, and Behavior Reports. Often, this report is used first by the nurses to understand priority changes and decide whether to drill down into more specifics using other On-Time Reports.

Summary of Key Points

  • Using the Priority Report helps focus on residents with changes in clinical status from the previous week in factors placing residents at potential risk for developing a pressure ulcer.
  • Nursing often finds this a valuable report to start with each week to identify changes in items related to pressure ulcer risk. The Nutrition, Weight, and Trigger Summary Reports provide additional information to drill down into details.

Return to Contents

Step 6: Implement Process Improvements Using Red Area Report: Optional

This section describes the Red Area Report and how it can be used as a checklist by licensed staff to monitor red areas on the skin, as documented by Certified Nursing Assistants (CNAs). This report and associated process improvements are valuable to a facility if CNAs document skin observations electronically and the facility wants to use CNA documentation in a formal skin monitoring process.

This process improvement is considered optional because not all facilities have CNAs recording skin observations daily and therefore lack access to the Red Area Report electronically. This process improvement may be implemented if your facility has the following:

  • Health information technology system that supports CNA skin observation documentation.
  • Policy in place that specifies how CNA documentation of skin observations is used by licensed staff.
  • Process for communicating skin observations.

This section provides:

  • Orientation to the Red Area Report.
  • Suggested steps to implement a process improvement using the On-Time Red Area Report.
  • Implementation tips from nursing homes that have implemented this process improvement.
  • Frequently asked questions.

Orientation to the Red Area Report

The Red Area Report lists residents with noted red areas based on CNA daily skin observations. A resident with at least one documented occurrence of a red area during the report week will display in the report.


The Red Area Report can be used as a worksheet for followup, with space for notes. The computer generates resident names, based on CNA data entry of skin observations. The remainder of the report is blank for handwritten notes. In the sample report (Table 6.1), the following columns are blank for note taking: Requires Followup, Followup Notes, New, Existing, and Initials. Sample information has been inserted to show how columns may be completed.

Process Improvement Using Red Area Report


Facility teams determine how the Red Area Report is used. We provide examples of process improvements for teams to consider (Table 6.2). While specific work steps may vary by facility, the primary objective is to establish a formal process to confirm red areas on residents that display on the report.

The nurse identifies the need for additional education for CNAs if errors in CNA documentation are noted or if residents with known red areas are not on the Red Area Report.

The staff educator:

  1. Reviews the completed worksheet and follows up on residents that do not have red areas after rechecked by nurse.
  2. Determines education or inservice needs and follows up.

Implementation tips follow:

  • Identify "super users" in CNA staff to promote accurate documentation of red areas in skin observation section by following up with staff each day and helping to answer questions from other CNAs as needed. Super users can be "go-to" CNAs for nurses for followup. Examples of nurses assigned to review the Red Area Report include charge nurse, wound nurse, and staff educator.
  • Try a variety of processes used by teams to follow up and address nurse notations on the worksheet:
    • Wound nurse follows up.
    • Lead CNA or CNA in role of skin advocate follows up. In this scenario, the nurse reviews the report and marks residents for followup by a CNA. The CNA lead uses the worksheet to follow up with peers to confirm that red areas are present or no longer present. The lead CNA communicates to the nurse, who conducts a followup skin assessment or provides other directives to CNAs.
    • Wound nurse and lead CNA tag team followup. In this scenario, the wound nurse establishes a relationship with one or more CNAs who serve as part of the wound nurse team to routinely follow up on Red Area Report information. The wound nurse then updates the red area worksheet.

"Using the Red Area Report has helped the project team identify staff inservice needs. It has resulted in very productive discussions that led to team leaders making changes to the communication process."

— Staff Educator

"Use of the Red Area Report helped the communication between CNAs and nurses expand from a CNA verbal report to the nurse to CNA and nurse collaborative discussions of 'what is a red area' and 'what are care plan interventions' that CNAs need to focus on."

— Unit Manager

Frequently Asked Questions

Question: If a CNA documents "red area" one time during the week, will the resident show up on the report?

Answer: Yes. If red area is entered by the CNA at least once during the week, the resident will display on the weekly report. Teams use the report as a worksheet to doublecheck that red areas have all been followed up on. Some health information technology systems provide additional documentation details, including the person who documented the information and the date.

Question: Red area documentation by CNAs is often inaccurate. How have other teams addressed this issue?

Answer: When On-Time teams start this process, often they find more reported red areas than actual. However, the teams report that the focus on red areas is very positive for CNA education and CNA communication with nurses. It also helps raise CNA awareness of pressure ulcer prevention efforts. Over time, red area documentation improves in conjunction with improved team communication. Consider the following educational strategy to improve CNA understanding and documentation of red areas:

  • Involve staff educator, wound, or skin team nurse to provide an inservice on proper documentation of red areas.
  • Work with lead CNA to help with training of peers (develop a plan to include all shifts and weekend staff).

Question: We already have a process for CNAs to verbally report a red area to the nurse before documenting. How will using the Red Area Report help us?

Answer: Teams use the Red Area Report as a worksheet to confirm that followup on red areas has occurred and that care plans are updated each week. Using the Red Area Report does not replace the verbal reporting that is in place, but rather is a doublecheck that nothing falls through the cracks.

Question: Can the discussion of red areas be part of the 5-minute standup meetings?

Answer: Often On-Time teams will discuss residents with red areas at the 5-minute standup meetings. This reinforces the importance of CNA documentation accuracy and the CNAs' role in care planning.

Question: Can we use the report as a worksheet for the CNAs?

Answer: Yes. Each facility interested in establishing a formal process to monitor red areas, as recorded by CNA staff, develops a process that works best for the facility.

Question: What have facilities found most helpful about this process?

Answer: Teams have reported that CNAs are more aware of the definition of "red area" due to ongoing feedback from nurses. In addition, teams report that CNAs have an increased understanding of the importance of their role in picking up on resident red areas. CNAs report that they are paying more attention to skin observations during daily routine care. Teams report an increase in CNA accountability and improved nurse followup.

Question: Our CNAs are instructed to report red areas as soon as they are discovered; we do not wait until the end of the shift or day. This does not seem like a timely process.

Answer: The process to review the Red Area Report does not replace facility procedures for CNAs to report red areas immediately upon discovery. The process serves as an adjunct to current practice.

Question: Do teams report the process to monitor red areas as being too time intensive?

Answer: Most teams that have implemented this process say that review of the Red Area Report does add time but the upfront effort to routinely follow up with CNAs leads to an increased awareness by CNA staff and thus fewer red areas and fewer pressure ulcers to manage. Teams report that the time invested in this process is shorter than the time invested in managing a pressure ulcer from identification to heal.

"The process serves as a good doublecheck and we are picking up a few red areas that we may not have known about."

— Nurse Manager

Summary of Key Points

  • Using the Red Area Report:
    • Improves CNA accountability for skin observation documentation.
    • Identifies inservice needs for CNAs.
    • Provides a doublecheck to confirm that nursing has followed up on all reported red areas on the skin.

Return to Contents

Step 7: Monitor Impact

This section provides an overview of the measures and tools that can be used to monitor the impact of the On-Time process improvements. Monitoring impact is an important step for several reasons:

  • Provides feedback to the team.
  • Shows the results of implementing new processes.
  • Helps identify the need for process refinements.

Each facility establishes a process to gather and summarize key measures on an ongoing basis. Key measures include clinical outcomes, measures of quality of care, and process measures, including Certified Nursing Assistant (CNA) documentation completeness rates. Key measures are collected at baseline and before implementing On-Time process improvements; they continue on a quarterly basis after implementation.

The primary quality measure monitored in the On-Time quality improvement (QI) program is pressure ulcer incidence. In addition, teams monitor two Centers for Medicare & Medicaid (CMS) quality measures: pressure ulcers in high-risk residents and weight loss. The primary process measure monitored is CNA documentation completeness rates before and after On-Time QI implementation to track how On-Time QI efforts affect the CNA documentation process.

This section provides:

  • Definitions of key measures.
  • Data collection strategies and tools.
  • Frequently asked questions.

Clinical Outcomes

Since preventing the development of pressure ulcers is the central focus of On-Time, the clinical outcome measures are related to pressure ulcers. Each team establishes a process to collect and track the primary measure: incidence of new in-house pressure ulcers. In addition, On-Time teams monitor two CMS quality measures: pressure ulcers in high-risk residents and weight loss. This section provides definitions of each measure, details regarding the data, and data collection tips.


Select Table 7.1 for a Clinical Outcome Measure Summary.

Incidence of New In-House Acquired Pressure Ulcers

The incidence of new in-house acquired pressure ulcers is monitored monthly for each unit. It is defined as the percentage of residents on unit (or facility) with newly developed in-house pressure ulcers that month. Specifically:

  • Numerator = Number of residents with one or more newly identified pressure ulcers developed this month while the resident was in the facility (in-house acquired). Do not count ulcers that developed outside the facility (e.g., in hospital or prior to admission).
  • Denominator = Average monthly census for the unit (calculated based on method in place at facility).

Important measurement considerations include:

  • Definition of pressure ulcer: Any sore/lesion caused by unrelieved pressure resulting in damage to underlying tissue and that usually occurs over bony prominences (AHCPR, 1992). Pressure ulcers most commonly occur over the coccyx or sacrum, trochanter, and heels. They also occur over any bony prominence or area exposed to pressure. Include Stages I through IV and unstageable. Do not include vascular or diabetic ulcers or skin tears.
  • In-house acquired vs. outside-acquired (or present on admission or readmission) are to be determined according to CMS guidelines: if the ulcer is first observed within 24 hours of admission (regardless of state), it is present on admission. If it is first observed more than 24 hours after admission, it is in-house acquired.


Typically, in-house pressure ulcer rates can be computed from data reported on existing facility pressure ulcer monthly reports. A tool is provided to guide a team through the calculation. These data can be collected on paper or electronically, depending on facility current processes. Select for the data collection tool.

Frequently Asked Questions

Question: Who typically collects this information?

Answer: In most cases, the wound nurse, director of nursing, or assistant director of nursing is responsible for gathering and computing the monthly in-house pressure ulcer incidence rate for each unit. Since they usually review the monthly pressure ulcer reports produced by each unit nurse coordinator, it is a natural step for them to report the in-house rates.

Question: Our nursing units produce monthly reports of all pressure ulcers on the unit, including the new in-house pressure ulcers. Can we use this information?

Answer: Yes. These data can be used. There are several options to calculate the in-house incidence rate for each unit if this is not done currently: (1) The data collection tool can be used to calculate the in-house incidence rate; or (2) a team can consider using an electronic spreadsheet to capture monthly reporting data and calculate the in-house incidence rates.

Question: We have in-house pressure ulcer rates calculated at the facility level. Is this good enough?

Answer: No. Since each unit is implementing the On-Time program, it is important to track the data specific to each unit to show progress and provide feedback to each team.

Question: How often are pressure ulcer incidence data reviewed with the teams?

Answer: Teams establish a schedule that works for them. Typically, the pressure ulcer incidence data are graphed and reviewed with the teams at least every quarter. Many teams review the data monthly.

CMS Quality Measure: Pressure Ulcers in High-Risk Residents

The CMS high-risk pressure ulcer measure is monitored because it is easily gathered and is a commonly accepted measure of quality. Although a measure of prevalence (not incidence), it is affected by reduction in pressure ulcer incidence. This measure is available on a quarterly basis (lagged measure 6 months old) for monitoring and review by the facility.

This measure is defined as the percentage of high-risk residents with pressure ulcer (includes both in-house and outside acquired). The publicly reported quality measures are available at the CMS Nursing Home Compare Web site.

CMS Quality Measure: Weight Loss

The weight loss measure, a clinical outcome measure related to pressure ulcer development, is monitored because it is easy to collect and often shows improvement prior to reducing the pressure ulcer incidence rate. The CMS measure for weight loss is available on a quarterly basis (lagged measure 6 months old) for monitoring and review by the facility.

This measure is defined as the percentage of residents with significant weight loss (5 percent in 30 days or 10 percent in 180 days). The publicly reported quality measures are available at the CMS Nursing Home Compare Web site.

Frequently Asked Questions

Question: We already track facility-level in-house pressure ulcer rates. Do we have to calculate unit-level in-house pressure ulcer rates?

Answer: Unit-level data are strongly suggested for several reasons. Unit-level data can be shared with staff on each unit so that they can participate in monitoring their progress. Implementation of On-Time process improvements takes place at the unit level. Corresponding unit-level measures of impact, when available, help monitor impact for each unit and provide feedback on progress. The overall facility rate may mask variations across units and may not reveal units that have increasing rates even when the overall facility rate is declining.

Question: Why are we using both in-house pressure ulcer rates and the CMS quality measure to monitor impact?

Answer: On-Time teams monitor both measures for different reasons. The unit-level in-house pressure ulcer rates are the primary clinical outcome measures targeted by the On-Time process improvements. These data are available in a timely manner and can be directly related to resident characteristics and prevention efforts on each unit. The CMS quality measure, reported with a 6-month lag time, is monitored because of its strategic importance to the facility. It is publicly reported and used in the 5-star rating system.

Question: Where can I access the CMS quality measure data?

Answer: The CMS Nursing Home Compare Web site: http://www.medicare.gov/NHCompare.

Question: Are the CMS quality measures reported at the unit or facility level?

Answer: The CMS quality measures are reported only at the facility level.

Question: Since there is a 6-month lag in the CMS data, do we report these data on a different schedule than the in-house pressure ulcer rates?

Answer: The quality measure data can be reported at the same time as other measures but you should clearly note that the data have a 6 month lag due to the CMS reporting schedule.

Process Measure

As discussed in the CNA documentation completeness step, we suggest that teams monitor and provide feedback to team members on the CNA documentation completeness rates at the unit level. This shows immediate impact of QI efforts and demonstrates credibility that QI efforts are leading to improvement.

Below are the definition of CNA documentation completeness rates, details regarding the data, and data collection tips for teams to consider.

The CNA documentation completeness rate is a process measure monitored to assess On-Time impact. A central focus of the On-Time program is standardizing and redesigning CNA documentation elements and then summarizing CNA documentation in On-Time clinical reports. One direct result of On-Time implementation is that CNA documentation completeness rates go up in direct proportion to the use of On-Time reports in process improvements. More complete CNA documentation provides better information for the entire team to use in planning care and assessing the needs of residents.

The CNA documentation completion rate is the average percentage of documentation completed over a week for all residents on a unit:

  • Numerator = Number of shifts with completed documentation during report week.
  • Denominator = Total number of shifts that the resident is in the facility during the report week.

Completeness rates are calculated at baseline and 12-month postimplementation.

Completeness rates are computed for specific sections required for the On-Time program:

  • Meal intake.
  • Bowels.
  • Bladder.
  • Behaviors (optional).
  • Skin Observations (optional).

CNAs are expected to complete these sections each shift of every day, and 100 percent completeness is expected.

The baseline completeness rate is measured by conducting an audit of a sample of charts on each unit. The postimplementation completeness rates are measured using On-Time Completeness Report data.

Frequently Asked Questions

Question: How many charts should I audit to establish a completeness rate at baseline?

Answer: Typically, teams select 10 charts to audit completeness rates at baseline.

Question: How are these data reported to the teams on an ongoing basis?

Answer: Typically, the Documentation Completeness Report information is shared and posted on each unit on a regular basis (weekly or monthly). Often, teams produce graphs to show the trends to team members.

Summary of Key Points

  • Establishing a process to monitor key measures to assess impact is an important step at the start of On-Time and throughout implementation.
  • Key measures are used by the leadership group to monitor impact and are presented to frontline teams to provide feedback on process improvement efforts.
Page last reviewed January 2011
Internet Citation: On-Time Implementation (continued): 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/qimanual4b.html