Results

On-Time Prevention of Pressure Ulcers

The results are reviewed in three sections: implementation progress, levels of facility implementation, and outcomes.

Implementation Progress

Implementation started in a phased approach in the second quarter of 2006, with facilities continuing to start implementing in 2007 (Table 3). 

Table 3. Facility Implementation Start Date

Start DateCAAZIDNCTotal
Q2 '0642  6
Q3 '066  17
Q4 '065  16
Q1 '07  1 1
Q3 '071   1
Total1621221
Facilities discontinued2 1 3

* These facilities are in the process of deciding whether to reengage in the project. The main consideration is whether they have the corporate and facility leadership capacity to support implementing On-Time.

On average, it took the project team 4 to 6 weeks to support a facility team through the initial stage of addressing certified nurse assistant (CNA) documentation completeness issues and questions related to the new documentation form. Then, on average, it took the project team 6 to 8 weeks to support a facility team gaining basic understanding of clinical reports and deciding where and how to integrate reports into daily practice. This implementation cycle was shortened by 3 to 4 weeks for all facilities joining from Q3 2006 onward because sharing the experience of the initial six facilities accelerated the standardized documentation process for the other facilities.

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Levels of Facility Implementation

During Q4 2007, the project facilitators assessed the level of implementation at each facility (Table 4). Two-thirds (67%) of facilities demonstrated a high or moderate level of implementation. 

Table 4. Level of Facility Implementation Grouped by Start Date

Level of Facility ImplementationQ2 2006Q3 2006Q4 2006Q1 2007Q3 2007Total% Total
High423  943%
Moderate211  1524%
Low0421 733%
Total (21 facilities)6761121 

The assessment of implementation level was based on facilitator and team collaborations on conference calls, onsite visits, feedback, and progress reports from team members as part of their QI process, and discussions at the all-facility meeting. Several characteristics were used as criteria in the assessment, specified in Table 5 below. 

Table 5. Characteristics of High, Moderate, and Low Levels of Implementation

#Major Work StepCharacteristicHighModerateLow
1Project preparation

Designated a project lead

Ongoing collaboration with project facilitator

Multidisciplinary team participation

Yes

Yes

Yes

 

Yes

Yes

Yes

Yes
2CNA form redesignImplemented new CNA formYesYesYes
3Information technology (IT) installation and testing

IT installation

Staff assigned to manage use of IT and provide ongoing support

Staff assigned to troubleshoot internal technology issues

Yes

Yes

Yes

Yes

Yes

Yes
4Review CNA documentation completeness and accuracy

Weekly monitoring/audit process in place

Established process to follow up on incomplete and/or inaccurate CNA documentation; assigned responsibility and followup

Yes

 

Yes

Yes

 

Yes

Yes
5On-Time report use weekly or biweekly or monthly

Plan for using On-Time reports

Clear assignments for team members

Use of On-Time reports by various team members

Yes

Yes

Yes

Yes 
6Workflow and process improvement initiatives

Integrated On-Time reports into existing meetings

Implemented new processes, such as:

  • 5-minute stand-up meetings with CNAs
  • Structured end-of-shift report by CNAs to nurses (AHRQ format or other)
  • Primary role in project by CNA team leaders
Yes  
7Monitor progress and assess impact

Participate in collaborative multifacility workgroups

Participate in assessing impact

Yes

Yes

Yes

Yes

 

In summary, facilities with a high level of implementation compared to facilities with a low level of implementation took the following steps:

  • Designated a project lead—collaborated with project facilitator to support team participation and confirm that On-Time activities were carried out.
  • Had a multidisciplinary team participate in On-Time activities.
  • Adopted processes for implementing On-Time within own facility process and structure; made clear assignments for team members.
  • Had various team members use On-Time reports.
  • Integrated On-Time reports into existing meetings and implemented new processes, such as 5-minute stand-up meetings with dietary staff and CNAs.

Facilities with a moderate level of implementation took clear steps to get started implementing On-Time, but did not fully integrate On-Time reports into the daily work of the multidisciplinary team. These facilities focused on the first step of implementing the redesigned CNA documentation form, used the Completeness Report to improve CNA documentation completeness and accuracy, and started to make a plan to use other reports.

Facilities with a low level of implementation did not commit leadership or team time to implement On-Time and were not compliant with project activities. Three of the seven low implementers are the facilities that discontinued the project and are in the process of deciding whether to reengage. The remaining four low implementers did not have leadership that believed that On-Time was a priority and did not participate on project conference calls or commit to implementation. Another common characteristic of facilities with a low level of implementation that prohibited integration of clinical reports into daily work was challenges implementing Health IT due to lack of IT knowledge internally or lack of onsite IT support.

Specific differences follow:

  • Project Lead, Team Composition, and Participation

    Establishing a core project team early in the project that included multiple disciplines and a designated project leader was key to successful implementation of program activities and the facility's ability to sustain On-Time processes.

    Facilities with a high level of implementation had a project leader who was committed to full implementation of project activities to achieve results and team members who were included in all aspects of the project. High-performing facilities had a dedicated core team that took responsibility for project success and participated on scheduled team calls with the International Severity Information Systems (ISIS) facilitator. In the facilities with a high level of implementation, several members of a multidisciplinary team were involved, including administrator and director of nursing (DON), Minimum Data Set (MDS) nurse, dietitian or diet technician, staff development, and CNAs.

  • In facilities with moderate and low levels of implementation, the effort was led by the DON and staff development and project responsibilities were not distributed across a multidisciplinary team. In facilities with a low level of implementation, a multidisciplinary project team was not in place. Typically, the project leader was the only one who participated on facility calls with the project facilitator; it was difficult to implement the program with this structure in place.
  • Streamlining and Standardization of CNA Documentation

    All facilities streamlined and standardized CNA documentation and implemented the new documentation process. The difference between facilities with high and low levels of implementation was that in the facilities with a high level of implementation, a full complement of staff participated in managing the new workflow and technology. High-performing teams delegated project responsibilities to the appropriate staff. For example, Medical Records typically took ownership of auditing CNA documentation forms for completeness; MDS nurses, dietitians, and Social Services assumed responsibility for reviewing components of CNA documentation for accuracy. They also worked closely with the staff educator to establish followup plans for CNA in-service training when needed; staff were assigned to manage processes associated with support of the technology.
  • On-Time Report Use

    All the facilities with a high level of implementation used the Completeness Report to monitor CNA documentation completeness rates and to identify potential CNA documentation issues. Well-established processes to review the Completeness Report, including staff followup, were in place. All high-performing facilities integrated at least one clinical report into weekly care planning. The Nutrition and Priority Reports were used most often at existing interdisciplinary team (IDT) meetings, weight variance committee meetings, or MDS reviews. The Behavior Report was used occasionally at Behavior Management meetings. The DON, staff developer, dietary staff, QI staff, and MDS nurse were key users of reports in all facilities implementing On-Time. Typically, the Completeness, Nutrition, and Priority reports were the first three that the teams started to use. The facilities with a high level of implementation had additional report users, including unit managers, charge nurses, wound nurses, CNAs, and social services.
  • Workflow Redesign and New Process Initiatives

    Most high-performing facilities (66%) implemented the weekly 5-minute stand-up meetings with CNAs to review meal intake. The process varied by facility, e.g., used Nutrition or Priority Reports; however, all who implemented the process reported success in earlier identification of residents at risk. This success was attributed to improved communication with CNAs and licensed staff.

    Three facilities (33% of high performers) implemented a structured end-of-shift format to focus CNA reports to nurses at the end of their shift. Nurses reported that they received better information from CNAs.

    A total of 66 percent of high performers designated CNA team leaders to play a primary role in the project, e.g., serve in support role, lead meetings, follow up with CNA staff on incomplete or inaccurate charting.

Outcomes

The impact at the nursing homes implementing On-Time is summarized below in Table 6. 

Table 6. Summary of Impact

Area of ImpactMeasureImpact Summary (December 2007)
Clinical outcomes

Incidence of new in-house-acquired pressure ulcers (PrUs)

Centers for Medicare & Medicaid Services (CMS) quality measure (QM)—% high-risk residents with PrU

CMS QM - % weight loss

 

Declined from 4% to 2.3% in the high implementers (n=8) (approximately 1.5 to 2 PrUs per 100 beds)

Declined 12.4% (12.1% to 10.6%) in all On-Time facilities (n=17)
Declined 30.5% (13.1% to 9.1%) in the high implementers (n=7, 2 facilities did not report data)

Declined 7.8% (7.7% to 7.1%) in all On-Time facilities (n=17)
Declined 37.0% (9.2 % to 5.8%) in the high implementers (n=9)

CNA documentation

Completeness of CNA daily documentation (specifically in meal intake, behavior observations, skin observations, Activities of Daily Living [ADL])

Accuracy of CNA documentation

Improvements in CNA documentation completeness reported (DON, director of staff development [DSD], dietary staff, and MDS nurses)

Improvements in CNA documentation accuracy reported (dietary staff and MDS nurses)

Workflow efficiencies (based on feedback from 12 facilities)

Identification of residents at high risk

Communication of high-risk residents by dietary staff, wound nurses, MDS nurses, CNAs, Nursing

MDS nurse and dietary staff time spent gathering and validating data (MDS information, care plan meetings, family conferences)

Improvements reported in identifying residents at risk and communication among team members (facility feedback)

 

Reduced time gathering information (dietary staff and MDS nurses)

CNA satisfaction

CNA satisfaction

  • Valued as member of team
  • Involved in interdisciplinary team discussions
Improvements in CNA satisfaction reported (facility feedback)

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Detailed Review of Data

Clinical Outcomes

The in-house PrU rates for the facilities with a high level of implementation declined from a quarterly rate of 4 percent to 2.3 percent (approximately 1.5 to 2 PrUs per 100 beds).

On-Time QI in Long-Term Care
Quarterly Pressure Ulcer Incidence Rates
(acquired in-house)
8 facilities (900 beds)—high level of implementation

Line graph showing high implementer combined rate from 2006 quarter 1 to 2007 quarter 3. Implementation period was 2006 quarter 2 to quarter 4.  Rates are: 06 Q1, 4%, 06 Q2, 4.5%, 06 Q3, 3.6%, 06 Q4, 4.1%, 07 Q1, 2.7%, 07 Q2, 2.6%, 07 Q3, 2.3%.

The monthly in-house PrU rates in September 2007 for the high implementers show a continued downward trend to 1% for all facilities combined.

On-Time QI in Long-Term Care
Monthly Pressure Ulcer Incidence Rates
(acquired in-house)
8 facilities (900 beds)— high level of implementation

 Line graph showing high implementer combined rate for January 2006 through September 2007. Implementation period was April to December 2006. Rates are: Jan 06 4%, Feb 06 4%, Mar 06 4%, Apr 06 3%, May 06 6%, Jun 06 5%, Jul 06 4%, Aug 06 4%, Sep 06 4%, Oct 06 4%, Nov 06 3%, Dec 06 5%, Jan 07 3%, Feb 07 3%, Mar 07 2%, Apr 07 2%, May 07 3%, Jun 07 3%, Jul 07 3%, Aug 07 3%, Sep 07 1%.

The high-risk PrU quality measure declined 8.6% (11.6% to 10.6%) between Q1 2006 and Q2 2007 for all On-Time facilities combined (calculated from 17 facilities with QM data implementing On-Time as of Q4 2006). For the facilities with a high level of implementation, high implementers, the high-risk PrU quality measure declined 30.5% (13.1% to 9.1%) between Q1 2006 and Q2 2007. In comparison, the national data increased 4.2%.

Line graphs showing pressure ulcer rates from 2005 quarter 2 to 2007 quarter 2. Implementation started from 2006 quarter 2 to quarter 4. Rates are: High implementers (n=7) combined Q M, QM 05 Q2, 11.1%; QM 05 Q3, 11.0%; QM 05 Q4, 10.2%; QM 06 Q1, 13.1%; QM 06 Q2, 13.0%; QM 06 Q3, 10.7%; QM 06 Q4, 9.8%; QM 07 Q1, 7.0%; QM 07 Q2, 9.1%; Non-high implementers (n=10) combined Q M, QM 05 Q2, 17.3%; QM 05 Q3, 14.6%; QM 05 Q4, 13.3%; QM 06 Q1, 12.9%; QM 06 Q2, 13.3%; QM 06 Q3, 12.8%; QM 06 Q4, 14.5%; QM

Double Arrow Percent change in QM Q1 06 to Q2 07 

High implementers: - 30.5%
Non-high implementers: +11.6%
All On-Time facilities: -8.6%
National: +4.2%

The weight loss quality measure increased slightly (7.3% to 7.4%) between Q1 2006 and Q2 2007 for all On-Time facilities combined (calculated from 19 facilities with QM data implementing On-Time as of Q4 2006). For the facilities with a high level of implementation, the weight loss quality measure declined 18.5% (8.1% to 6.6%) between Q1 2006 and Q2 2007. In comparison, the national data decreased 2.2%.

Line graphs showing weight loss quality measure rates from 2005 quarter 2 to 2007 quarter 2.  Implementation started from 2006 quarter 2 to quarter 4. Rates are: High implementers (n=9) combined Q M, QM 05 Q2, 6.8%; QM 05 Q3, 8.1%; QM 05 Q4, 6.9%; QM 06 Q1, 8.1%; QM 06 Q2, 9.1%; QM 06 Q3, 8.8%; QM 06 Q4, 6.9%; QM 07 Q1, 7.6%; QM 07 Q2, 6.6%; Non-high implementers (n=10) combined Q M, QM 05 Q2, 7.5%; QM 05 Q3, 9.5%; QM 05 Q4, 7.9%; QM 06 Q1, 6.5%; QM 06 Q2, 8.7%; QM 06 Q3, 8.6%; QM 06 Q4, 7.6%; Q

Double Arrow Percent change in QM Q1 06 to Q2 07

High implementers: - 18.4%
Non-high implementers: +26%
All On-Time facilities: +2%
National: - 2%

CNA documentation. Overall, facilities reported improvement in CNA documentation completeness and accuracy. Review of the data postimplementation showed that facilities maintained consistent CNA documentation completion rates greater than 75 percent for the sections of the form required for clinical reports: meal intake, bowel, bladder, and behavior documentation. Staff feedback from team conference calls was that CNAs have a better understanding of charting requirements now that Nursing is meeting with them weekly to review report (charting) results. In addition, CNAs can see the link between their daily documentation and information on the reports.

Workflow and staff satisfaction—feedback from facility project lead, MDS, and dietary team members. The areas of impact related to workflow and staff satisfaction are summarized based on facility team feedback:

  • Identifying high-risk residents: Facility teams reported improvements in identifying high-risk residents in the following areas: residents with decreased meal intake, weight loss, behavior changes, increased urinary incontinence, and ADL decline.
  • Workflow efficiencies: Facility teams reported that the greatest impact on workflow was in the following activities: QI monitoring, preparation for MDS assessments, medical record audits of CNA documentation, and preparation for State surveys.
  • Staff satisfaction: Facility teams reported that the most improved staff satisfaction was with the CNA staff. Improved CNA staff satisfaction was associated with increased involvement in resident care discussions. Facilities with a high level of implementation reported improved satisfaction with other members of the team, such as MDS nurses and dietary staff.
  • Nurse to dietary staff communication: Facility teams reported that the greatest impact on communication was improvement in communicating about residents with significant decreases in meal intake and significant weight loss. Dietitians have an earlier awareness of residents with declining meal intake or weight loss.
  • Staff nurse to wound nurse communication: Facility teams reported that the greatest impact on staff nurse to wound nurse communication was improvement regarding residents with significant decreases in meal intake and significant weight loss.
  • CNA to nurse communication: The greatest improvement in communication occurred regarding behavior changes, red areas on skin, new open areas, and ADL decline. Nurses reported that communication of resident needs to nurses by CNA staff has improved since the shift worksheet was implemented. CNA staff report feeling more confident that nurses are aware of care being provided during their shift.
  • Also, facility leadership reported that they have taken a "giant leap" toward technology use and understanding Health IT at the facility.
Page last reviewed March 2009
Internet Citation: Results: On-Time Prevention of Pressure Ulcers. March 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcers/puqio4.html