Process Improvement Discussion Guide

On-Time Quality Improvement for Long-Term Care

This Guide provides assessment questions and process improvement considerations. The On-Time program is funded by the Agency for Healthcare Research and Quality (AHRQ), with support from the California Healthcare Foundation, to improve long-term care by turning daily documentation into useful information that enhances clinical care planning.

I. Completeness Report

Current Process: Assessment QuestionsProcess Improvement Considerations
  1. Who is responsible for monitoring certified nurse assistant (CNA) documentation?
  2. What is the followup to form incompletion?
  3. What processes are in place to determine if a chart is incomplete? What is measured/audited?

1. Use for Documentation Audits:

  1. Schedule routine chart review: weekly/bi-weekly.
  2. Assign responsibility for specific sections: e.g., MDS RN review Behaviors, Dietary review Meal Intake.
  3. Establish routine followup with CNA staff and determine topics for in-service schedule, for example, how to document behaviors or how to document skin observations section.
  4. Staff to review post-trended completeness rates on units.

II. Nutrition Report

Current Process: Assessment QuestionsProcess Improvement Considerations
  1. How are residents at nutritional risk identified? What are the criteria?
  2. What information is communicated? To whom is information communicated? When is it communicated? How is it communicated?
  3. What is dietician role in this process? Nursing?
  4. Are there standard interventions for followup for residents with low meal intake? Are interventions standardized across facility?
  5. Are CNAs aware at the beginning of their shift of residents who have:
    • Not been eating well?
    • Lost weight?
    • New pressure ulcer?
    • Worsening pressure ulcer?
    How is information communicated? What is the CNA responsibility?
  6. What processes are in place to associate meal intake trends and worsening pressure ulcer status?

1. Weekly 5-Minute Stand-Up Meeting

  1. Schedule brief weekly team (CNA, Dietary, Nursing) review of Nutrition Report, e.g., 5-Minute Stand-Up Meeting to review medium risk residents.
    • Does report information match clinical picture?
    • Do residents have tube feedings? Supplements?
    • When was the last dietary consult?
    • Does resident also have a pressure ulcer (PU)?
  2. Establish standard protocols/interventions:
    • Clear action steps post meeting, i.e., if meal intake decreased and weight loss in past week, dietary notified and CNA offer snacks throughout day.
    • Followup on CNA action items before shift ends.

2. Integrate report findings into Care Planning meetings.

  1. Assign responsibility to print and discuss Nutrition Report as part of care plan meeting.
  2. Confirm that resident care plans address identified risk indicators like decreased meal intake, etc.

III. Trigger Summary Report

Current Process: Assessment QuestionsProcess Improvement Considerations
  1. Who is responsible for monitoring unit trends? What criteria are evaluated?What is the process?
  2. How are new program opportunities identified? Prioritized?

1. Integrate report findings into weekly high-risk Interdisciplinary Team meetings and/or Care Planning meetings.

  1. Review trigger totals by resident each week.
    • Identify residents with change in triggers by 2 or more.
    • Confirm report results are consistent with clinical picture.
    • Establish standard action plan/protocol for risk indicators.
  2. Confirm PU prevention practices are in place for high-risk residents.
  3. Confirm communication plan.
  4. Confirm that care plans are developed based on resident needs—PU Trigger report.

2. Consider using report during Quality Improvement (QI) Team meetings

  1. Assign responsibility for evaluating/monitoring unit trends; establish standard action plan/protocols (e.g., IF # residents with foley catheter =>20% unit census THEN.)
Page last reviewed June 2007
Internet Citation: Process Improvement Discussion Guide: On-Time Quality Improvement for Long-Term Care . June 2007. Agency for Healthcare Research and Quality, Rockville, MD.