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Frequently Asked Questions

On-Time Quality Improvement for Long-Term Care

Answers to questions about the On-Time Quality Improvement for Long-Term Care Program.

 

Contents

What is the On-Time Quality Improvement for Long-Term Care Program?
Why Should a Facility Adopt On-Time?
How Many Nursing Facilities Have Participated or Are Working with On-Time?
How Does a Facility Participate in On-Time?
How Does On-Time Reduce Pressure Ulcer Rates and Improve Quality?
What Has the Program Accomplished to Date?
What Is Required of My Facility?
What Resources Are Needed to Participate in On-Time?
What Assistance is Available?
Would Participating in On-Time Mean More Work for Staff?
Do We Have To Use a Specific Information Technology Vendor to Participate in On-Time?
What Do Other Nursing Facilities That Have Participated in On-Time Say About It?
Are New Tools Being Developed?

 

What is the On-Time Quality Improvement for Long-Term Care Program?

The On-Time Quality Improvement for Long-Term Care Program is funded by the Federal Agency for Healthcare Research and Quality (AHRQ), generally in collaboration with a State Department of Health, a Quality Improvement Organization (QIO), or a trade association, to improve nursing home care. The focus is on prevention and timely treatment during routine care. Current tools focus on prevention and treatment of pressure ulcers and related risk factors such as unnecessary weight loss, incontinence, and changes in behaviors.

Tools, including standardized certified nursing assistant (CNA) documentation elements and clinical reports, have been developed with participating staff in more than 30 pilot facilities. The goal is to improve clinical information and integrate that information into facility daily work flow so that improved communication between CNAs, dietary staff, MDS coordinators, social work, and nurses will result in more timely referrals, treatments, and changes in care plans. With the help of quality improvement consultants, facility staff work in multidisciplinary teams to consolidate and standardize CNA documentation, assure the completeness and accuracy of documentation, and use a set of reports and tracking tools to identify high-risk residents, improve information flow among the multidisciplinary team, improve documentation of preventive care, and make more timely referrals and treatments. Reports can be accessed at least weekly and provide summary trend information.

All On-Time tools, documentation elements, and reports can be integrated into health information technology (health IT) products used by the facility or a facility may choose to begin using paper forms and then up-grade to health IT when purchased. About seven health IT vendors have programmed the "On Time" tools. Additional help is provided if the facility is integrating On-Time with new health IT.

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Why Should a Facility Adopt On-Time?

There are several reasons why a facility should adopt On-Time:

  • Identify residents at risk for pressure ulcer development sooner to prevent adverse consequences.
  • Improve timely flow of clinical information among CNAs, dietary, and nurses.
  • Improve documentation of CNA observations and make it a valuable tool to identify changes in risk factors, such as weight loss and incontinence.
  • Receive weekly clinical reports that summarize clinical changes over time for high-risk residents.
  • Reduce in-house pressure ulcer formation and weight loss.
  • Improve documentation of prevention practices.
  • Increase CNA job satisfaction and involvement in multidisciplinary quality improvement teams.
  • Move your facility from a fragmented, paper-based environment to a more efficient electronic-based environment.
  • Improve team-based care planning.

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How Many Nursing Facilities Have Participated or Are Working with On-Time?

As of the summer of 2008, 55 nursing facilities located in 9 States and the District of Columbia have participated in the pressure ulcer prevention and healing studies, including 17 in California, 16 in New York, and 7 facilities in the District of Columbia.

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How Does a Facility Participate in On-Time?

Facilities have been given the opportunity to participate in the On-Time program when their QIO or Health Department has partnered with AHRQ to support implementation. We currently are working with facilities in New York, California, and the District of Columbia. If you are interested in this program, please E-mail us at On-Time@ahrq.hhs.gov. Alternatively, please contact your local QIO or Health Department to determine if they are interested in implementing the program. Also, we are interested in working with nursing home chains that would like to implement this program and integrate it into their health IT acquisition plan.

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How Does On-Time Reduce Pressure Ulcer Rates and Improve Quality?

The On-Time program provides participating facilities new tools and skills to improve the prevention of pressure ulcers. The program provides the pressure ulcer team with simple weekly reports that summarize changes in the clinical status of high-risk residents for pressure ulcer development. These reports are used to make more timely changes in the resident's care plan. Nursing home staff work in a multidisciplinary team and harness improved clinical information documented daily by CNAs to increase the power of interdisciplinary team discussions and communication. A key component of the work is bringing the entire clinical care team—CNAs, dieticians, nursing coordinators, and managers—to the table with the reports and engaging them in discussions about workflow, documentation, and care planning. Weekly feedback reports address documentation completeness, behavior, nutrition, high-risk indicators for pressure ulcer development, and incontinence trends. Once the program ends, facilities should have a high-quality pressure ulcer prevention program in place for many years to come as well as a core set of skills and tools that can be used to help manage nutrition and behaviors and also help MDS nurses with their documentation needs.

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What Has the Program Accomplished to Date?

The initial pilot program achieved an average 33 percent reduction in pressure ulcer prevalence within a year among 11 participating nursing homes. Some facilities reduced prevalence by up to 73 percent and incidence by up to 65 percent. In most recent data from the next phase of implementation with 21 facilities, for facilities with a high level of implementation there was a 30.7 percent decline (from 13.1 to 9.1 percent) in CMS high-risk pressure ulcer quality measure and a 42 percent decline in in-house pressure ulcer rates (from 4 to 2.3 percent). This implies that a facility that had about 4 new pressure ulcers acquired in house each quarter can reduce this rate to about 2 and, if they adhere to the program, keep the rate at that level. All facilities report improved documentation and better identification of residents at risk for pressure ulcer development and improved interdisciplinary communication processes.

In addition, CNA clinical care staff have become very engaged in the program and, as a result, more involved in overall quality improvement efforts. They like the fact that the program has reduced the number of documentation forms they have to fill out every day and they find great value in the On-Time feedback reports. These positive experiences help create a "culture of data," a key step in quality improvement that creates the foundation for integrating health IT into nursing home care.

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What is Required of My Facility?

Your facility must have a high pressure ulcer rate and have a strong interest in migrating from a paper-based environment to an electronic, data-based environment. You will need to replace your current CNA documentation forms with standardized documentation, which can be adapted to your needs. You also must be willing to participate in working phone meetings led by a program team facilitator to transform your CNA documentation and to incorporate the On-Time reports into your work flow. You also will need to use the reports to improve staff communication and clinical decisionmaking. In addition, you will be required to participate in program phone meetings to share in experiences with workflow transformation with other participating facilities.

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What Resources Are Needed to Participate in On-Time?

The resources needed to participate are an health IT system and staff time.

The resources for health IT will depend on the type of technology your facility decides to implement or already has available. You may use existing technology or invest in low-cost technology for an estimated $15,000 for an average 100-bed facility plus annual license and support fees.

For staff time, a core group of clinical staff will be asked to 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 documentation forms, redesign workflow, and integrate clinical reports into daily work processes.

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What Assistance is Available?

The following assistance is available to program participants:

  • Ongoing program management and implementation support throughout the 2-year program.
  • Regular communication regarding program status and impact.
  • Facilitation of regular conference calls to support workflow redesign and implementation.
  • On-site training to support use of On-Time clinical decisionmaking reports by front-line caregivers.
  • Conference calls among multiple facilities to share lessons learned.

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Would Participating in On-Time Mean More Work for Staff?

On-Time is viewed as an 18-month to 2-year facilitated quality improvement program that is then transitioned to ongoing practice. It is important to keep in mind that clinical staff are asked to invest a portion of their time up front in regular meetings, phone calls, and training to standardize documentation and redesign clinical workflow. But many front-line staff have said this investment has been well worth their time. Also, depending on your status of health IT system selection and implementation, leadership team members will spend additional time working through these steps.

CNAs report that the program has made their work more efficient, productive, and rewarding. Streamlined documentation reduces the number of forms they have to fill out. More importantly, the On-Time reports serve as a key tool for supporting resident care, rather than add-ons that generate more work and headaches.

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Do We Have To Use a Specific Information Technology Vendor to Participate in On-Time?

You do not have to use a specific information technology vendor to participate in this program. Each facility's leadership and clinical care team are responsible for deciding the health IT vendor and product based on the everyday challenges that staff face and what they believe can be done to make their work easier, more efficient, and more effective. The requirement for the health IT vendor is that they meet the requirements of the On-Time program: confirm the required CNA data elements are captured and the standard On-Time reports are produced. Each vendor selected will be asked to undergo the On-Time requirements evaluation and review process.

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What Do Other Nursing Facilities That Have Participated in On-Time Say About It?

Feedback from participating nursing facilities has been overwhelmingly positive. "One of the best things... is the focus on CNAs as important members of the team providing critical information for clinical decisionmaking," one nursing director said. Another nursing manager remarked about how engaged CNAs were in the program and eager to progress to the next level of participation. "It is so important as we try to increase the responsibility of the front-line clinicians for clinical decisionmaking," she said. Others have described their experience in the program as collaborative, exciting, and valuable. Several facilities have noted that by participating in the On-Time program they have been able to implement their health IT system to a greater extent and build the capacity of their front-line team members to use the clinical reports to improve care for their residents.

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Are New Tools Being Developed?

Yes. We are currently developing a form to document pressure ulcer healing and treatments and a set of reports to help with monitoring of the healing process. Facilities generally add these tools after they have mastered the prevention program.

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Current as of November 2008
Internet Citation: Frequently Asked Questions: On-Time Quality Improvement for Long-Term Care. November 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/qualityimprov/ltcfaq.html