AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention
Implementation Steps and Timeline
The goal of On-Time is that a facility staff will incorporate the On-Time reports into day-to-day prevention activities and ensure multidisciplinary input into clinical intervention decisions. The Implementation Steps document was created to help nursing homes understand steps involved in implementing On-Time and the likely timeline to make the reports part of daily practice. It is intended to be used by the team champion and the Change Team members to help keep the effort on track and methodical. The timeline is meant as a guide, because quality improvement project timelines often vary, depending on the quality improvement skills and resources available to the participating facilities.
Step 1: Agree To Use On-Time Falls Prevention
Nursing home leadership agrees to incorporate process improvements using On-Time reports into their workflow. Most facilities begin with changes in workflow on one unit and then expand use to all units. Leadership agrees to identify a change team champion and establish a multidisciplinary Change Team to lead the project.
Step 2: Contact Vendor
The Change Team champion or information technology (IT) representative contacts the facility’s electronic medical record (EMR) vendor to confirm that On-Time falls prevention reports are in the system and takes appropriate steps at the facility to provide all necessary staff with access to prevention reports.
Step 3: Identify Multidisciplinary Team Members To Serve as the Change Team
The Change Team consists of a Change Team champion, nurse managers from each nursing unit, a therapist (e.g., the rehab director), and nursing assistants. The champion advocates and supports the project and ensures project activities are sustained during turnover of key staff. Nursing leadership may assume this role or delegate the responsibility. Two team leaders co-facilitate project activities; one is a nurse and the second can be from nursing or another discipline.
Team leaders share responsibilities to coordinate and implement activities and coordinate calls with an On-Time Facilitator. The director of nursing determines his or her level of involvement. Ad hoc team members include the staff educator, physicians, nurses, and representatives from other disciplines.
Step 4: Introduce On-Time Fall Prevention
The On-Time Facilitator provides technical assistance via an initial telephone consultation to confirm EMR capabilities and readiness to start On-Time, discusses immediate next steps regarding IT, and guides staff through the introductory materials as needed. The Facilitator answers questions and confirms that the facility team members understand how to access reports and tools and establishes the process for working together.
Step 5: Review Reports
The team reviews reports with the Facilitator to understand content and potential use of reports.
Step 6: Complete Self-Assessment
The team completes the Self-Assessment Worksheet that identifies details about the current processes at the facility to identify residents at risk for falls and to coordinate care planning. The review includes identification of team meetings, huddles, and other communication structures in place, ways risk information is transmitted to clinical staff, and ways care plans are updated and interventions determined. The team is guided by the Facilitator to identify gaps and begin to think about ways On-Time reports can be used to help prevent falls.
Step 7: Pilot a Report With Data
The On-Time Facilitator assists the team in using one of the reports. The team reviews material for the first report and generates the report for one nursing unit. The Facilitator works with the team to understand the first report and answers questions, as needed.
Step 8: Validate Data
This step helps the team gain confidence in the validity of the data in the reports. The team discusses residents populated on the report to ensure that data on the report agree with staff knowledge of residents’ health/risks. Staff may choose to go back to the medical record to confirm that data on the report are consistent.
In completing this task, the team may identify problems in, for example, nursing assistant documentation completeness, and may find it necessary to have the nurse educator retrain nursing assistants, to improve report validity. In addition, the Facilitator can clarify any normal but potentially confusing data situations and how to interpret them. Each report the team uses should go through this process so the team is confident in the information being produced on the reports.
Step 9: Agree To Use Reports/Implementation Strategies
With the Facilitator, the Change Team uses the Fall Prevention Menu of Implementation Strategies. The Facilitator describes the strategies and helps the team determine which reports may help them given the findings from the self-assessment (Step 6). The team can use one report more than one way and in multiple meetings.
Step 10: Create Report/Meeting Strategies
Strategies are based on self-assessment identification of pre-On-Time communication and care plan meetings/huddles and the Fall Prevention Menu of Implementation Strategies. Some new huddles and other meetings may be created and meetings may be altered to accommodate report discussion.
The team reviews the Fall Prevention Menu of Implementation Strategies for each On-Time report and discusses options for using the reports within current communication structures. The team considers meetings, huddles, care plan meetings, or other existing meetings where a report would enhance the current process to identify risk and coordinate care across disciplines.
At this time, the team identifies potentially new processes that may be developed to use the reports. Teams pilot reports and incorporate report discussion into existing meetings or new meetings. Changes in requirements to attend meetings may be needed to increase the number of disciplines and nursing assistants providing input and to change communication networks to improve risk identification.
The Facilitator helps the team initiate the first report meeting strategy. The team makes sure it understands the criteria for identifying residents profiled on the report, knows the definitions of risk factors that are profiled, and receives advice on how to structure existing meetings or create new meetings to best incorporate report discussions. Advice includes who should attend the meeting, what their roles are, who is responsible for the reports, and who will lead the discussion.
Step 11: Pilot All Report/Meeting Strategies on One Unit
The team discusses implementation issues with the Facilitator after piloting of report/meeting strategies. This is an iterative process that should be repeated until the process is smooth and effective.
Step 12: Ensure Implementation Strategies Are Carried Out
Once a new report is incorporated into a meeting, the champion decides on role changes for staff to ensure the report is used at designated meetings with appropriate discipline and nursing assistant input. It is important for the champion to have supervisory responsibility so these changes can be informed and enforced.
Step 13: Develop Plan and Implement New Strategies in All Units
The training and implementation planning process for integrating reports on one unit should take approximately 3 to 4 months once the facility has confirmed the On-Time Fall Prevention reports are available and staff have been granted access to view and print the reports (Steps 3-12). The timeline depends on leadership commitment, stability of staff, staff familiarity with computerized reports, and quality improvement (QI) experience of staff.
Implementing on all units is likely to add another 3 months. The Facilitator will help the team to problem solve implementation issues until all reports and all units are implementing the reports as planned and the team becomes more independent.
Step 14: Monitor Facility Implementation Progress Monthly
After about 6 months, the Facilitator’s role is to check in to identify obstacles that could occur and to troubleshoot issues such as turnover of key staff, computer glitches, and implementation issues. The expectation is that reports will be used on a weekly basis except for meetings that occur less frequently (e.g., monthly).
Step 15: Review Fall Incidence
The Facilitator works with the team to generate QI monitoring reports that identify fall rates to provide feedback to the Change Team and support reporting requirements.
Step 16: Sustain the Effort
After approximately 9 months, the nursing home Change Team develops a plan for incorporating implementation strategies for report use into facility policies and procedures. The plan includes incorporating education regarding On-Time into routine educational inservices, including for newly hired staff and training material for temporary employees. A permanent On-Time champion and champions on units should be identified by facility leadership.
Likely champions for each nursing unit are the nurse managers, with backup support by a QI staff member who may be assigned to conduct periodic monitoring of the processes surrounding the use of the On-Time reports in order to ensure that their use is sustained. The director of nursing or a designee should assume the responsibility of ensuring On-Time process improvements are carried out on each nursing unit.
|Implementation Steps||Estimated Duration/Time From Implementation|
|1. Agree to Use On-Time Fall Prevention|
|2. Contact Vendor||Start time is after confirmation of access to reports for frontline staff|
|3. Identify Multidisciplinary Team Members To Serve as the Change Team||Within 2 weeks|
|4. Introduce On-Time Falls Prevention||1st month|
|5. Review Reports||1st month|
|6. Complete Self-Assessment||1st month|
|7. Pilot a Report With Data||2nd month|
|8. Validate Data||2nd month|
|9. Agree To Use Reports/Implementation Strategies||2nd month|
|10. Create Report/Meeting Strategies||2nd month|
|11. Pilot All Report/Meeting Strategies on One Unit||2nd month|
|12. Ensure Implementation Strategies Are Carried Out||3rd month to 4th month (some facilities implement in all units simultaneously)|
|13. Develop Plan and Implement New Strategies on All Units||4th month to 6th month|
|14. Monitor Facility Implementation Progress Monthly||6th month to 9th month|
|15. Review Fall Incidence||As required|
|16. Sustain the Effort||End of 9th month to 12th month|