Discussion: Lessons Learned

On-Time Prevention of Pressure Ulcers

Lessons learned are summarized in five sections: implementation process, organizational obstacles, training, health information technology (Health IT) implementation and support, and partnering with Quality Improvement Organizations (QIOs) . 

Implementation Process

There were several lessons learned related to the On-Time implementation process:

  • Involvement of certified nurse assistants (CNAs) in the transition to the new documentation process supported success. Successful teams started with a core group of CNAs or a lead CNA to communicate the standardization effort among CNA staff, attend meetings, discuss documentation changes with fellow CNAs, and elicit feedback. The CNAs participated in the training process. Facility teams used one of the following approaches as they transitioned to the new standardized form: started with a pilot unit to work through initial content or process issues or started with a CNA preceptor or CNA leads who documented a subset of residents.
  • CNA documentation required ongoing monitoring and followup by staff to maintain accuracy and high documentation completion rates. Successful teams developed a structured process with clear accountability to monitor CNA documentation completion rates on a daily basis initially, then weekly, until high completion rates were sustained.
  • Report use by front-line teams requires concrete strategy. Facility teams that were successful adopted one or more of these strategies:
    • Give specific assignments to staff members to use reports and provide feedback to the DNS.
    • Have reports reviewed and discussed by clinical team members (not just reviewed by one person).
    • Target meetings where report information is used to support care planning discussions, e.g., Behavior report for behavior management meetings, Nutrition report for weight variance meetings.
    • Start small: Focus on one or two reports for team use and a subset of report data versus all available report information.
    • Use specific report results to trigger focused intervention, e.g., residents with red areas (Priority Report) require review by a skin nurse or wound team to confirm results.
    • Keep review of report information focused: Do not slip into lengthy meetings that keep staff away from direct resident care, e.g., review residents with decline in meal intake and focus on nutritional interventions.
    • Identify how a report can eliminate manual work or make work easier for staff.
    • Provide ongoing training and follow up on reports: how to access, how to print, and when to use.

      Use of clinical reports is a paradigm shift for nurses; nurses require continual monitoring and support to integrate reports into care planning processes. The use of reports was greater in facilities with leadership committed to strengthen the skills of the front-line clinicians in multidisciplinary collaboration around the care of residents. Also, leaders who understand the use of data and quality improvement teams are strong advocates for the use of reports by front-line staff in daily work.

  • Nursing home chains require a more complex project management approach. Working with several facilities that were part of a chain, we identified the need to establish routine leadership progress reports and conference calls in addition to the routine implementation team conference calls. Given the more complex management structure within a chain, the leadership team does not overlap with the implementation team as it does in independently owned facilities. Expect greater lag time from plan to implementation due to the lengthy approval process required by large corporations.
  • Routine progress tracking by facility leadership is required. To better engage all facility teams in monitoring implementation progress, the International Severity Information Systems (ISIS) facilitators organized periodic feedback sessions via conference call. In addition, several facility teams provided summary points highlighting successes and challenges. The goal in future On-Time efforts will be to have each team provide quarterly feedback on progress via both conference call and written report.

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Organizational Obstacles

Managerial challenges were considered in our implementation planning and were assessed during implementation at each facility. We refined strategies to address each issue.

  • Leadership hesitation to participate. The biggest barrier to getting nursing homes to participate was leadership having the time needed to make the decision regarding participation and the Health IT investment. Every nursing home provider we spoke with saw the value of the project, but having them decide to participate in the project within 1 or 2 months often was difficult.

    It took time for people to understand this "new" approach to quality improvement and process redesign. Unless they hear it multiple times or can get confirmation from someone they already know and trust, many providers see the value of the project but are not able or willing to participate as an early adopter.

    We grouped facilities into these general categories:

    • Ready to participate and need little time to decide.
    • See value but unable to decide within project deadlines.
    • Skeptical of the intervention (unable to see the value in the process redesign and use of technology at their facilities; perceive this effort as "one more thing for staff and management to do").

    Key characteristics of nursing homes that decided to participate were the following:

    • Need help lowering pressure-ulcer (PrU) rate.
    • Very interested in taking first steps toward automation but cannot afford an electronic health record.
    • Very interested in standardizing CNA documentation and streamlining process.
    • Would like to improve CNA satisfaction.
    • Recognize the need to improve systems of care related to using information at the front line for better clinical decisionmaking (e.g., shift report, interdisciplinary communication).
  • Resistance to change documentation or lack of buy-in, e.g., challenges for team members moving from known paper documentation logbooks to unknown standardized documentation forms and automation, perception that documentation takes more time and is more complicated than previous processes. The perception that we worked to overcome was that this project is "one more thing for staff to do"; instead we promote the proven track record of the project and the fact that the effort will bring considerable value to staff and residents.
  • Staff turnover. Staff turnover is common in long-term care facilities. To address this challenge, training materials, plans, policies, and procedures for using standardized documentation forms were included in new staff orientation. CNA team leaders, if in place, were responsible for supporting new staff or agency staff in learning the process.
  • Administrator and director of nursing (DON) turnover. Turnover at the management level is common in long-term care facilities. When a change in leadership occurs, it is important to allow time for the facility to adjust to the change. The impact depends on the extent that responsibility for process improvement is shared with key staff or the primary responsibility of the DON. The project team established a working relationship with at least two people for site project coordination. In addition, a strong relationship between the project facilitator and the core team was established on facility-specific calls and onsite visits.
  • Site-specific needs and customization requests for standardized documentation forms and reports. We encouraged all facilities to standardize their documentation forms. How to support variation in documentation data elements across sites is an ongoing challenge for Health IT vendors.
  • Resistance to adopt reports and redesign processes to use reports. Quality Improvement skills and knowledge varied in participating facilities. Understanding the role and function of QI resources within each facility was essential. Knowledge of each facility's QI process allowed the project team to incorporate change elements into a structure that was familiar and comfortable to that facility's team. Use and experience of multidisciplinary teams within facilities varied. Does a foundation for teamwork exist? Is a facility taking its first steps forming a team of CNAs, RNs, Minimum Data Set (MDS) RNs, dietary staff, etc.?

    An implementation team established at each facility provided a forum for ongoing communications about barriers, adoption, and organizational pressures or unforeseen issues. This partnership approach with project team facilitators and project management provided an objective participant (ISIS) focused solely on supporting the facility in successful implementation and results. It is often helpful when addressing organizational and cultural issues to have an external facilitator review options and provide perspectives from other facilities. In addition, networking with other participating facilities provided valuable insights into successful approaches that have been discovered elsewhere.

  • Resistance to delegate project responsibilities to implementation team members. Roles and responsibilities of all team members were defined for each participating facility. Since each facility had different resources and levels of expertise available, ISIS established needs with each facility and defined roles and responsibilities of project team members accordingly with input from the facility. Each implementation team reviewed team roles at standard intervals to make adjustments or refinements.
  • Competing priorities that develop over time. The project management team was a constant during the project and a resource with grant funds dedicated to the project for each facility. Workplan reviews were conducted every month to confirm timelines and assess resource utilization and gaps. Each work step was detailed specifically so that the team could assess barriers, delays, and resource issues. We allocated ISIS and facility time based on detailed plans and reviewed and revised as needed.

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  • The feedback loop to review completeness and accuracy of CNA documentation was an ongoing process for each facility. The DSD conducted regular in-service training and the lead CNA worked closely with peers to correct documentation issues. Also, agency and relief staff did not always complete documentation, resulting in incomplete forms and reports. All CNA staff needed close supervision early in the process; well-defined process steps with clear accountability helped keep the process running smoothly.
  • The ability to more easily monitor CNA documentation surfaced issues with CNA understanding of daily documentation requirements that were not known previously. CNA documentation has required ongoing in-service training for CNA staff. Facilities spent more time than anticipated on CNA in-service training for appropriate documentation. While this may have been an issue with previous documentation forms, inaccurate or incorrect documentation patterns were not easily seen because of the manual process to review each form individually. The online Completeness Report summarized documentation errors for nursing leadership review and followup.

    The Completeness Report provided nursing leadership with a mechanism to support CNA documentation audits. In the past, this manual process was very time consuming and not conducted consistently. Now, teams can conduct chart audits more frequently, recognize charting issues earlier, and establish a plan to follow up with CNA staff to correct the problem.

    Five-minute stand-up meetings with CNA staff revealed areas where CNAs "misunderstood" appropriate documentation. For example, one facility reported that CNA staff were not correctly documenting meal intake. This was discovered during routine review of Nutrition Report results with nursing and CNA staff. Another facility discovered that CNAs were not clear about "incontinence" and what it meant as evidenced by documentation inconsistencies reported on the Completeness Report for bowel and bladder documentation.

  • Facilities were at varying levels of understanding of how to use information to improve care planning processes for quality improvement versus "find bad apples" or quality assurance (QA). The ISIS team collaborated with QIOs to assess level of understanding within the nursing home leadership team of QI versus QA. This is an area that required further discussion in planning for next phases.

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Technology Implementation and Support

  • IT knowledge deficit of nursing home facility teams. Most of the facility teams had little to no IT knowledge before the project started. A few team members were PC literate; most had to be trained. Facilities without a "go-to" person to answer technology questions or to support the digital pen processes had more difficulties sustaining project activities than facilities with access to immediate IT support.

    Implementing new technology in nursing homes, no matter how simple to use, requires dedicated resources to support the new forms and processes. It is difficult to integrate IT into an environment with little to no onsite technical support.

  • Dedicated staff time needed on an ongoing basis for Health IT implementation in nursing homes. For example, digital pen processes, while "low-tech," required daily monitoring by facility staff and assignments for ongoing operation (ensure that pens were working properly and data were uploaded). Health IT maintenance and monitoring, even for a low-cost solution such as the Digital Pen Systems technology, are an ongoing responsibility at the facility. Since this was a new technology used in nursing home settings, the following expectations were learned over time by the teams:
    • Staff Development, Medical Records, and often CNA leads or charge nurses need to be responsible for ensuring that data are uploaded.
    • Medical Records needs to be responsible for managing online census updates.
    • Staff Development needs to be responsible for fielding technology process questions from staff on an ongoing basis and training new staff on how to use new technology.
    • The administrator needs to be responsible for troubleshooting technology issues for staff and communicating with the Health IT vendor.
  • Initial lack of confidence in report data. All facility teams sometimes questioned the report data. The feedback loop to review completeness and accuracy of CNA documentation was an ongoing process for each facility. Building team confidence in the accuracy of the data entered and the Health IT system's ability to capture the data is a critical step before using reports. If clinicians cannot obtain accurate clinical reports consistently, it is difficult to regain team confidence in electronically generated reports.
  • Lack of timely support from vendor. There was a need to establish a routine process to monitor data uploads for facilities using the Digital Pen Systems technology solution. The ISIS facilitators worked with Digital Pen Systems to develop an ongoing process and report to monitor pen uploads and completeness of data transfer.
  • Large effort needed for ongoing customization. Standardized CNA documentation forms contain approximately 90 to 95 percent common data elements across facilities. However, there were both State and facility needs that required approximately 5 to 10 percent customization of data elements for each facility. IT programming staff originally estimated and budgeted for three versions of CNA forms to meet the needs of all facilities. Because each facility form required some level of customization, form development and testing effort by the vendor teams was greatly increased.
  • Health IT project versus process improvement initiative. Facilities that encountered ongoing challenges with Health IT implementation often lacked full-time Health IT support at the facility, resulting in a focus on the technology versus process improvement initiatives.

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Partnering With QIOs

  • QIO teams were valuable and supportive partners in recruiting. QIO team members became well versed in providing a project overview and discussing the business case for the project.
  • QIO team members could not devote large amounts of time to direct involvement in the implementation process. Due to resource cuts and limitations of the 8th Scope of Work, QIO team members were limited in their time. We worked with the teams to identify critical milestones in the implementation process for them to participate and supplemented this experience with ongoing calls with the ISIS team.
  • It was a natural fit for the QIO team to work with multiple facility teams to sustain how they use reports in daily activities. To date, we have had several discussions with QIO team members about questions, such as, How could the QIO adopt Real-Time in the future and what would be the QIO role? Discussions related to report use could happen across many facilities versus a focus on specific issues at one facility. We worked with participating QIOs to build a strategy for sustaining quality improvement in PrU prevention and discussed strategies and plans for each QIO to move the project forward in additional facilities in their State.
Page last reviewed March 2009
Internet Citation: Discussion: Lessons Learned: 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/puqio5.html