On-Time Prevention of Pressure Ulcers

Study Design

The project team, working with Quality Improvement Organization (QIO) partners and provider facilities, used a process established in "Real-Time" to redesign workflow quickly (rapid cycle improvement) and to adopt process change. We incorporated:

  • Core data elements developed and refined over a 2-year period by 11 pilot facilities to streamline documentation processes and incorporate key measures of quality for certified nurse assistant (CNA), wound nurse, and Care Team use.
  • Feedback reports for improved care planning and clinical decisionmaking. Five weekly reports were created using CNA data:
    1. Completeness report for CNA documentation.
    2. Nutrition report.
    3. Behavior report.
    4. "Trigger" report that identified residents at high risk of pressure ulcer (PrU) formation.
    5. Priority report that provided an overall summary.
    Each report displayed resident-specific information for each unit.
  • Clinical workflow redesign strategies that improved operational efficiencies, improved communication among clinical team members, and reduced PrU incidence.

The On-Time approach is designed to include CNAs in the redesign of workflow and to focus on strengthening relationships across disciplines and improving effectiveness of multidisciplinary team collaboration. The project team worked with each facility team to facilitate the migration from a paper document environment toward a data culture environment and to promote use of timely clinical reports by multidisciplinary teams for identifying high-risk residents and planning care.

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Data Collection and Sources

The data collection plan was part of the implementation plan at each site. For the clinical reports, data were collected from CNA daily documentation forms and used in the generation of feedback reports by the Health Information Technology (Health IT) system at each facility. For the impact assessment, quality measure data were collected from the Centers for Medicare & Medicaid Services (CMS) Nursing Home Compare Web site quarterly, existing facility reporting mechanisms were used to collect PrU incidence, and quality improvement teams at each facility gathered staff feedback on documentation and workflow changes as part of the On-Time program. The project team provided standardized data collection forms to assist staff in tracking staff feedback and impact on workflow. Baseline data were collected and submitted by each facility prior to redesign efforts and ongoing data were collected at 6-month and 12-month intervals postimplementation. Data included:

  • Clinical outcomes: PrU rates (incidence and prevalence).
  • CNA documentation measures: # forms, completeness, and accuracy.
  • Workflow measures: team communication, time spent gathering information.
  • Staff experiences: positive and negative feedback regarding process changes.

Additional sources of information regarding the implementation experience were the ongoing conference calls with facility and QIO team members. Information gathered on these calls was used to identify implementation obstacles and lessons learned throughout the implementation process.

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Key Components of On-Time

The key components of implementing the On-Time program at a facility are:

  • Providing introductory and educational materials.
  • Assessing current CNA documentation, streamlining CNA documentation, incorporating best practice elements into daily charting, and consolidating CNA documentation into one form.
  • Establishing audit and feedback processes to confirm CNA information completeness and accuracy.
  • Integrating weekly reports that identify residents at risk into care planning processes and structures.

In addition, the project team provided ongoing project facilitation support to each facility team. Each of these components is described in more detail below.

Provide Project Facilitation

At each nursing home facility, we established multidisciplinary teams, consisting of the director of nursing (DON) or administrator, Minimum Data Set (MDS) nurse and wound care nurses, nurse-aides, dietitians, diet technicians, staff development, Quality Initiative (QI) coordinator, social services, and restorative care team members. By involving front-line staff in the redesign of workflow and implementation processes, the project aimed to strengthen collaborative relationships and improve communication and access to information across disciplines. These implementation teams championed the new clinical documentation and workflow redesign and provided daily leadership throughout the implementation process.

Ongoing biweekly conference calls were held with each facility team to provide technical assistance on how to facilitate workflow redesign at each facility (standardize data elements, consolidate forms, and use clinical reports in daily work to improve resident outcomes) and to review timelines, accomplishments of work steps, and next steps to be accomplished.

  • In first quarter (Q1) work with a facility, weekly conference calls were held with the facility implementation team to address the following: Introduce and review "Real-Time" reports and prototype forms; discuss strategies for integrating "Real-Time" reports (Nutrition, Weight Summary, Incontinence, and Behavior) into workflow; redesign facility documentation forms and review with team; assess workflow; plan to complete process observation forms and gather feedback from staff on workflow; plan for pilot test of documentation changes; establish process to review feedback from pilot test on form use; and plan full facility rollout.
  • In Q2-Q3 work with a facility, there were monthly calls to provide ongoing support for facility implementation teams and site-specific consultation and to develop a plan to use additional reports, e.g., high-risk PrU indicator and PrU tracking.
  • In Q2-Q6 work with facilities, there were regular weekly calls with all facility teams to provide ongoing support and discuss strategies to integrate On-Time into care planning.

In addition, quarterly conference calls were held for all participating QIOs to share learning and progress across States. Also, there was a conference call with each QIO and stakeholder group to review and discuss standard data elements and stakeholder requirements for documentation and quality reporting.

There was one face-to-face meeting with QIOs and selected participants from nursing facilities. At the 2-day meeting with QIOs and selected facility participants, we (1) discussed and compared experiences and outcomes to date; (2) discussed issues and problems in the course of the project and ways they could be addressed; and (3) identified any changes in the project approach.

A project team facilitator served as liaison between the facility and its Health IT vendor (including Digital Pen Systems, Optimus, and Vernon software development team) for workflow and clinical questions. The project team gave technical assistance to the nursing homes' software vendors to develop or adapt an electronic decision support system that:

  • Used the documentation electronically captured by CNAs from standardized clinical documentation forms and downloaded to the vendor's Web site.
  • Stored this information in a database and analyzed it.
  • Supported feedback to facilities in weekly reports that met On-Time specifications.

The project team identified two low-cost IT options for facilities to consider if they did not have an existing clinical IT system: the Digital Pen and Paper solution and Optical Character Recognition/Optical Marker Recognition (OCR/OMR). The Digital Pen and Paper is a customizable solution to transfer data from paper to a centralized database. It uses handwriting recognition and checkbox processing to manage documentation workflow with accurate capture of information in a digital format for processing. OCR/OMR is a data and document capture software solution that involves reading text from paper and translating the images into a form that the computer can manipulate. Data can be managed at the facility level or outsourced to a service bureau.

In summary, the project team provided the following support:

  • Collaborated with multidisciplinary implementation teams at each participating facility.
  • Helped to standardize and consolidate daily documentation for CNA staff, nurse care plans, and wound nurses.
  • Helped to implement a decision support system for collection, processing, and use of clinical data to support resident care planning based on "Real-Time" results: Nutrition, incontinence, behaviors, high-risk assessment for PrU development, and PrU tracking data elements and reports.
  • Helped to integrate reports for clinical teams into care planning processes and redesigned clinical workflow.
  • Tracked the impact of the quality change strategy on PrU development in high-risk residents and on workflow efficiencies:
    • Conducted baseline assessment and assembled ongoing data every 3 months.
    • Assessed impact on workflow.
    • Assessed learning of providers and QIOs: Assessed impact of AHRQ/QIO collaborative, identified areas of learning, and decided how and where to incorporate new techniques and methods into future plans.
  • Suggested sustainability plans for QIO and nursing home facilities and expansions to other nursing homes in participating provider organizations, other nursing homes in the State, other clinical areas and quality measures (QMs), and other QIOs.

The facility teams committed the following time:

  • Administrator and DON: 1 to 2 days to confirm project plans, discuss Health IT options, and finalize Health IT agreement with vendor.
  • Multidisciplinary team: weekly conference calls for the first 3 months lasting 30 minutes to 1 hour and biweekly calls for the next 12 months.
  • Staff development: 4 hours per week for the first 2 to 3 months to support initial implementation.
  • Consultants: 1-day meeting with the consultants on site.

Provide Introductory and Educational Materials

The project team prepared orientation materials to include information on project purpose, scope, benefits, expectations of providers, overall workplan and timeline, sample documentation forms and reports with explanations of use, and workflow redesign strategies.

Streamline and Standardize CNA Documentation Within Each Facility

Documentation forms currently used by CNAs were reviewed, cross-referenced against regulatory requirements, facility care protocols, and best practice elements, and compared to the On-Time CNA form prototype developed in "Real-Time."  Facility teams were guided through a self-assessment of CNA documentation at their facility by an AHRQ-funded project coordinator. The result of this process was the development of a new CNA form designed to include best practice elements and to eliminate both redundancy and documentation of nonessential items.

The new documentation allowed CNAs to spend less time filling out redundant paperwork and focused their documentation efforts on obtaining more precise information that was relevant to key risk factors and care planning.

Ultimately, CNAs transitioned away from paper forms and began Health IT, either currently in place or newly selected by the facility, to document daily charting. The project coordinators worked with facility vendors to ensure that elements of the On-Time program were incorporated into the Health IT application; this included data elements for CNA documentation and On-Time reports needed to support program implementation.

Use Reports for CNA Documentation Audit and Establish Feedback Process With CNAs

Using the Health IT selected by each nursing home, CNAs were able to capture and store data as they documented daily care on each shift; data were stored in a database and information was summarized in clinical reports to be used by multiple disciplines providing resident care.  

Since the On-Time PrU prevention reports were generated completely from CNA daily documentation, it was important to implement the Completeness Report first to audit CNA documentation. Teams became familiar with the Completeness Report first to manage documentation review. The Completeness Report summarized CNA documentation completeness and accuracy and served as a monitoring tool for early recognition of CNA documentation patterns. Medical records staff were able to use this report to identify incomplete CNA charting and staff educators were able to review the report quickly to determine areas of documentation that may require additional in-service and guidance. Staff educators played a key role in orienting staff to changes in documentation, identifying issues, and providing ongoing support of the entire process. Once high CNA documentation completeness rates were sustained, teams could review other reports with CNA staff to confirm report accuracy.

Integrate and Use Reports To Enhance Communication Across Disciplines and Promote Teamwork

The On-Time reports, designed with input from multiple disciplines, identified residents at highest risk for PrU development, showed trends in multiple outcomes for these residents over time, and helped staff monitor the effectiveness of care in a timely fashion. The project team focused discussions with the facility multidisciplinary clinical team on each report, including an overview of how it is used in care planning and examples of how to incorporate On-Time reports into weekly practices of multidisciplinary clinical team members.

The staff that typically used these reports were the director of nursing services (DNS or DON), assistant DON or DNS, MDS nurse, unit manager, charge nurse, dietitian, wound nurse, staff development, social services, and CNAs. The reports were used in existing meetings, e.g., Weight Loss Committee and Skin Team, as well as in new processes such as 5-minute stand-up meetings between dietitians and CNAs. These were examples only; the process could be customized according to each nursing home's goals and objectives.

The On-Time reports provided both information about specific residents and a snapshot of the facility's total resident population. Trend analyses provided by reports enabled clinicians to be more proactive in their care planning approach. For example:

Nutrition Report. This report was used to identify and monitor residents with decreased meal intake or weight loss, both of which are indicators for high risk of PrU development based on the guidelines. The weekly meal intake for the past 4 weeks was trended for each resident. Weight changes for the past 30, 90, and 180 days were calculated. This report helped staff answer the question, How many residents trigger for high risk (decreased meal intake of 2 meals ≤50% at least once during report week AND weight loss for report week)? Medium risk (decreased meal intake OR weight loss)?

Behavior Report. This report was used to summarize resident behavior trends by nursing unit and behaviors by resident by nursing station. This report helped nursing and social services staff review CNA observations of behaviors, identify changes in resident behaviors, understand patterns across shifts, and support the nurse behavior assessment and documentation processes.

Trigger Summary Report. High Risk for PrU Development. This report was used to monitor the number of PrU triggers by resident. It enabled staff to compare the current week to the previous week.

Priority Report. This report was used to identify and monitor priority residents, e.g., residents with changes from previous week, including decreased meal intake and weight loss; change in behaviors; increased bladder incontinence; and new PrU or worsened ulcer. It also monitored residents with red or open areas.

The initial focus of report use was on trended clinical information because subtle changes in resident status often go undetected as clinicians focus on day-to-day resident health status. The On-Time reports can be used to augment information generated by existing facility reports and processes to promote early identification of residents at risk. Staff were educated on each report and teams discussed potential opportunities for use. It was during this phase of the program that teams considered integration of On-Time reports into existing facility team meetings or determined whether there were opportunities for new communication forums using specific On-Time reports.

Another key initiative of the On-Time program to integrate report use and facilitate communication across disciplines was the implementation of 5-minute stand-up meetings with CNA staff, a process introduced during the pilot project. While facilities already may have a similar briefing process in place, the On-Time approach was distinctive in keeping the meeting brief, focused, and data driven. In these meetings, Nutrition Report results, which displayed residents at high or medium nutritional risk, were reviewed with CNA staff by the dietitian or nurse to confirm accuracy of report results. Once results were verified, clinicians could confirm that appropriate care plan interventions were in place and establish followup plans with front-line staff. In the 5-minute stand-up meetings with CNA staff, the teams reviewed the Nutrition Report, stayed focused on resident meal intake, and kept meetings brief to minimize time CNAs were away from direct resident care.

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The facility teams tracked measures related to four areas: clinical outcomes, CNA documentation, workflow, and staff satisfaction. Table 2 presents the measures that were used to track the impact of the project. We collected baseline and postimplementation measures. Postimplementation assessment occurred every 3 months. The project team compared change in PrU QMs in participating facilities with national norms. 

Table 2. Measures to Track Impact

#Area of ImpactMeasureData Collection Strategy/ToolTiming
1Clinical outcomes
  • Incidence of new in-house-acquired PrUs
  • CMS QMs—related to PrU (high-risk and low-risk residents)

Existing facility reports

CMS Nursing Home Compare



2CNA Documentation
  • # forms used for CNA daily documentation
  • Completeness of CNA documentation
  • Accuracy of CNA documentation
Staff feedbackQuarterly
  • Communication improvements
    • CNA to dietary
    • CNA to nurse
    • Nurse to dietary
  • Time spent aggregating and summarizing information (e.g., MDS information, regulatory reports, and family conferences)

Workflow analysis in conjunction with facility implementation team

Staff feedback

4Staff experience
  • CNAs valued as member of team
  • Staff feedback on impact of new processes
Staff feedbackPost-implementation

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There were some limitations to the "On-Time" quality improvement approach. Facility participation required both an interest in improving care and either an existing Health IT system for CNA documentation or the ability to invest at minimum in a low-cost Health IT solution (at least $5,000). The participation requirements biased the selection to those nursing homes that could comply. Many of the participating facilities had experience in quality improvement and working on process changes with a multidisciplinary team approach. Since the participating facilities all had a high-risk PrU QM of at least 8 percent, the facilities provided an appropriate sample to assess the dissemination of a previously developed intervention approach in a provider setting with opportunity for improvement.

Page last reviewed March 2009
Internet Citation: Methods: On-Time Prevention of Pressure Ulcers. March 2009. Agency for Healthcare Research and Quality, Rockville, MD.