On-Time Prevention of Pressure Ulcers

Background and Context

The U.S. Department of Health and Human Services launched the Nursing Home Quality Initiative in 2002. In the December 23, 2004, report from the Nursing Home Quality Initiative, the most negative statistic was that the percentage of residents with pressure ulcers (PrUs) increased slightly since measurements began in June 2002, from 8.5 percent to 8.7 percent. The rates persisted at about 13 percent for residents at high risk. High rates of PrUs in nursing homes remain despite major efforts by the Centers for Medicare & Medicaid Services (CMS) and training and education efforts by Quality Improvement Organizations (QIOs) across the country to reduce these rates. Reduction in PrUs remains a goal of the 8th scope of work for QIOs under contract with CMS. It was clear that a more effective strategy was needed to implement best practices in nursing homes and to support integration of best practices into daily workflow.

Preliminary successes of project activities in "Real-Time" resulted in changes to daily workflow and use of information within and among facilities. As a result of these interventions, there were large decreases in PrU rates among "Real-Time" project participants (averaging 33%) and great enthusiasm from participating staff. The "Real-Time" project developed and implemented a quality improvement strategy with 11 nursing homes. Project activities integrated quality improvement into daily operations to increase workflow efficiencies and simultaneously improve resident care. Project steps included the following:

  • Standardized certified nurse assistant (CNA) documentation elements and definitions across facilities (to the extent that similar information was gathered).
  • Streamlined CNA documentation within each facility: consolidated documentation to a small number of forms and eliminated redundant documentation.
  • Targeted specific education to one or more staff members when completeness reports indicated that their documentation in some clinical assessment area was inadequate.
  • Consolidated resident information via standard reports that reduced the time spent compiling information for care team meetings and outside agency reporting.

The "Real-Time" project provided the foundation for health information technology (Health IT) implementation by standardizing data elements, developing report templates, and redesigning care processes. These data and report definitions served as requirements for each facility's Health IT vendor as we finalized participation in the On-Time project.

Successes within "Real-Time" project facilities suggested potential benefits in widespread implementation of the "Real-Time" model in other nursing home facilities. The On-Time project was the next component of our strategy for dissemination in long-term care. Since QIOs work with nursing homes to improve quality, including PrU prevention, they were an ideal partner to help improve quality of care in nursing homes, to provide access to facilities for participation, and to join with State-level stakeholders to reach consensus on standardized data elements. The project team—a team from International Severity Information Systems (ISIS) and Health Management Strategies (HMS)—has been working together since 1995 on clinical practice improvement studies, best practices research, and implementation strategies for PrU prevention and treatment in long-term care facilities.

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We established and coordinated a facility recruitment plan and process with each QIO partner (California, Arizona, Idaho, and North Carolina). A packet of materials was prepared to introduce a facility to the project. We used multiple strategies to answer questions and recruit providers: group conference calls, individual calls, and presentations at several conferences. In addition, we facilitated conversations with Health IT vendors if a provider requested.

The eligibility criteria for participating facilities were:

  • Located in States of partnering QIOs.
  • PrU rate of at least 8 percent (high-risk resident PrU rate based on the CMS quality measure [QM]).
  • Interest in redesigning CNA documentation and workflow to reduce PrU rates.
  • Willing to invest in Health IT: Facilities without current Health IT capabilities had to be willing to invest in an Health IT solution that automated CNA documentation and produced On-Time reports.  

Recruitment efforts took place from September 2005 through September 2006. A total of 25 facilities provided verbal or written intent to participate, but 4 of these facilities had to withdraw at the last minute because of facility closure (1), corporate management team turnover (2), and lack of capital to invest in Health IT (1) (Table 1).

Table 1. Recruitment Summary.

Intent to participate
(verbal or written)
# facilities16222325
# beds1,7593032252506833,220
Actual participation
(formal project agreement)
# facilities16212021
# beds1,75930311025002,422

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There were 21 nursing home facilities and 4 QIOs that participated. To formalize expectations and roles, each participant signed formal agreements with the project team.

QIOs. A Memorandum of Understanding (MOU) was signed between ISIS and each QIO. The MOU included:

  • Overview of purpose and expected benefits of the project.
  • Overview of QIO roles and responsibilities. For example, each QIO was to integrate the On-Time project into CMS 8th scope of work requirements, facilitate selection and recruitment of participant facilities, facilitate discussions with stakeholders on reporting requirements, participate in conference calls with participating facilities and conference calls to monitor progress and to coordinate the project, agree to provide feedback to the ISIS team about intervention experience, and provide aggregate information on PrU quality measure data from identified comparison facilities. The QIO was expected to commit at least 10 percent full-time equivalent to the project over an 18-month period.
  • Specific ISIS team roles and responsibilities. For example, the ISIS team worked closely with the QIOs to coordinate facility selection, develop work groups in each State of five or six facilities, and work with the QIOs to transfer knowledge of On-Time techniques through joint conference calls and in-person sessions. ISIS worked with each QIO to develop a strategy to integrate the On-Time approach into its future workplan.

Nursing Homes. A Letter of Intent and a Project Participation Agreement were signed by each participating nursing home. In the agreement each facility agreed to the following:

  • Express commitment and high level of interest in an innovative QI effort for PrU prevention.
  • Commit facility resources (staff time) to promote a team culture of accountability, implement a low-cost technology solution, and achieve expected returns.
    • Assign project point person and participate in routine conference calls.
    • Form implementation team, including CNAs and multidisciplinary staff.
    • Participate in activities to assess impact: Participate in data collection pre- and postimplementation, including: staff feedback, unit-specific PrU incidence, and workflow measures.
  • Use existing Health IT or invest in low-cost technology.
Page last reviewed March 2009
Internet Citation: Scope: On-Time Prevention of Pressure Ulcers. March 2009. Agency for Healthcare Research and Quality, Rockville, MD.