AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits

Slide 1: Overview of On-Time

AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Facilitator Training

Overview of On-Time

Slide 2: On-Time Preventable Hospital and ED Visits Facilitator Training

• 2-day training provides:
  • Overview of On-Time.
  • Instruction on the role of a Facilitator.
  • Introduction to On-Time reports and implementation materials.
  • Hands-on practice using the reports and implementation materials in simulated situations.

Slide 3: Introduction to On-Time

• On-Time is a unique approach to quality improvement that focuses on the use of:
  • Electronic reports.
  • Multidisciplinary team.
  • Electronic medical record (EMR).
• On-Time provides clinical reports to help staff develop and implement appropriate interventions.
• On-Time uses Facilitators to help integrate these reports into existing workflow.

Slide 4: What Problem Are We Trying To Solve?

• Nursing homes investigate adverse events after they occur.
• Is it possible to intervene before adverse events occur?
• Does information exist to identify residents at risk?
• How can this information be used?

Slide 5: Discussion

• Can you think of examples when knowledge of risk factors might be used to prevent adverse events?
• What are obstacles to staff obtaining the information needed to identify residents who need changes in care plans? To intervene early? To intervene appropriately?

Slide 6: On-Time Reports for  Four Adverse Events

• Four Reports:
  • Pressure Ulcer Prevention.
  • Pressure Ulcer Healing.
  • Falls Prevention.
  • Preventable Hospital and ED Visits.

Slide 7: Common Elements of On-Time

• EMR used to develop reports that identify residents at increased risk of adverse events.
• Weekly reports to provide information to help staff intervene in a more timely manner.
• Implementation worksheets:
  • Help staff assess how they currently identify changing risk, make intervention decisions.
  • Identify ways to integrate the reports into day-to-day clinical discussions.
• Facilitator to help staff understand the reports and to guide integration of reports into day-to-day clinical decisionmaking.

Slide 8: Role of the Facilitator

• Establish relationship with Change Team:
  • Introduce On-Time Program and relevant electronic reports.
  • Review program expectations and establish a plan for regular communication.
• Guide the team to implement the program:
  • Provide training on report contents.
  • Guide the team’s completion and review of the Self-Assessment Worksheet.
  • Help the team identify ways to integrate the reports into current processes.
  • Help the team develop piloting strategy for fully integrating reports into daily practice.
  • Provide ongoing coaching and assistance to overcome obstacles during implementation.
• Monitor progress.

Slide 9: On-Time Implementation Prerequisites

• EMR vendor willing to provide access to On-Time reports.
• Commitment from key leadership, including the DON or administrator.
• Multidisciplinary change team and team champion.
• Commitment to provide high-quality data elements to populate reports.
• Commitment to work with the Facilitator to learn how to use the reports to prevent adverse events.

Slide 10: Functional Specifications and EMR Vendors

• Functional specifications are available for On-Time reports for each adverse event.
• Nursing homes would need to work with their vendor to:
  • Determine the availability of data elements required for each report.
  • Verify that staff are collecting accurate data to populate the needed data elements.

Slide 11: Facilitator Role: Preliminary Support

• Provide input on the composition of the change team and selection of program champion.
• Meet with program champion to explain facilitation role, and discuss nursing home responsibilities.
• Work with program champion to establish plan for working  together.
• Verify that reports are in the EMR system and can be accessed by all team members.

Slide 12: Evidence Base for On-Time Reports

• On-Time Program developed with funding from the Agency for Healthcare Research and Quality.
• Development of each report based on an extensive literature review of risk factors associated with adverse events.
• Input provided by nursing home staff familiar with nursing home operations and by leading clinicians.
• Reports tested in clinical settings for feasibility and ease  of use.
• Large decline in pressure ulcer incidence rate seen in Pressure Ulcer Prevention Program Evaluation.

Slide 13: Overview of On-Time Reports

• Are based on multiple sources of data from the medical record, including nursing assistant charting.
• Provide a snapshot at the resident, unit, or facility level for residents at high risk for adverse events.
• Are generated weekly.
• Can show trends occurring over time.
• Can provide treatment history.
• May focus on a particular risk factor.

Slide 14: Examples of On-Time Reports

• Examples from Preventable Hospital and ED Visits Reports:
  • Transfer Risk Report—High Risk.
  • ED Treat and Release Report.
  • Monthly Transfers by Facility or Nursing Unit.
  • Monthly Transfers by Provider.
  • Key Metrics Trend Report.

Slide 15: Facilitator Discussion: Value of On-Time Reports

• Focus on preventing adverse events.
• Proactive rather than reactive.
• Identify residents with recent changes in risks.
• Profile risks for each resident in report.
• Prioritize residents for possible changes to their treatment plan.
• Help clinicians determine appropriate interventions.

Slide 16: Teaching On-Time Reports

• The process for introducing the reports to the change team will follow a similar format regardless of the set of reports being presented:
  • Review report information to ensure participants understand:
    • How residents are selected to populate the report.
    • How all cell values are calculated.
  • Discuss how reports are useful.

Slide 17: Facilitator Role: Checking the Accuracy of On-Time Reports

• Advise team  that it is important to be confident that the information being presented about residents aligns with staff’s knowledge and assessment of these residents, or they will lack confidence in the reports.
• If staff feel the On-Time reports’ information is not accurate, propose they cross-check data in the On-Time report against medical record information:
  • Identify the questionable entries.
  • Review calculation details in report.
  • Check the accuracy of the data in the medical record.
  • Make corrections to the medical record as needed.
  • Check whether software “bug” is an issue.
  • Check that the medical record is complete.

Slide 18: Implementation Materials

• Implementation materials consist of:
  • Self-Assessment Worksheet.
  • Menu of Implementation Strategies.
  • Implementation Steps and Timeline.

Slide 19: Self-Assessment Worksheet

• Self-Assessment is divided into four sections:
  1. Screening: Explores what processes the facility uses to screen residents at risk for adverse events.
  2. Prevention Programs: Reviews information on existing prevention programs.
  3. Communication: Reviews existing team meetings/huddles that occur at the facility.
  4. Investigations/Root Cause Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur.

Slide 20: Self-Assessment Worksheet

• Each Self-Assessment Worksheet is designed to help nursing home staff review how they:
  • Screen for risks associated with each of the On-Time program’s adverse events.
  • Mitigate those risks.
  • Prioritize residents who may need care plan changes.
  • Discuss care plan changes.
  • Investigate the root cause when an adverse event occurs.
• The questions in each Self-Assessment Worksheet are tailored to the On-Time adverse event being addressed.

Slide 21: Facilitator Role: Encouraging Completion of Self-Assessment Worksheet

• The Facilitator encourages the champion to form a Change Team and plan how the Self-Assessment Worksheet is filled out.
• The Facilitator encourages the champion to lead a discussion to help the Change Team decide how to use the On-Time reports to help prevent the adverse event of interest.

Slide 22: Menu of Implementation Strategies

• Menu links On-Time reports with possible meetings that are recommended for discussion of On-Time report findings.
• Menu also identifies who should attend these meetings.
• Team works with menu and list of existing staff meetings from Self-Assessment Worksheet.
• Focus is on getting reports into existing meetings, if possible, or if not, identifying new meetings.

Slide 23: Facilitator Role: Using Menu of Implementation Strategies

• If needed, Facilitator helps team champion compare Self-Assessment list of existing team meetings with Menu of Implementation Strategies worksheet before team meeting and answers any questions.
• At meeting, team identifies meetings/huddles that can be used to discuss On-Time reports.
• Facilitator participates in meeting to help team with these decisions.

Slide 24: Facilitator Role: Incorporating Reports Into New Meetings

• Facilitator works with team to answer the following questions:
  • Who will lead the approval effort?
  • What administrative approvals will be needed?
  • Who should be present at the meeting?
  • When will the meeting occur?
  • Which reports will be used at the meeting?
  • Who will be responsible for generating the report, reviewing the report in advance, determining which residents will be discussed, and retrieving from the medical record any additional information needed?

Slide 25: Facilitator Role: Incorporating Reports Into New Meetings (cont’d.)

• Facilitator works with team to answer the following questions:
  • How will followup steps be determined and what other input will be needed to make changes in the care plan and/or make new referrals?
  • How will a timeline for changes and followup with nursing assistants and nurses be determined?
  • How will communication occur with other disciplines to confirm changes in care?

Slide 26: Facilitator Role: Incorporating Reports Into Existing Meetings

• Facilitator helps team determine:
  • How much additional time would be needed during the meeting if a new report were added to the discussion?
  • How would addition of reports affect  current meeting? Could the use of the report replace some of the time spent in presenting background information?
  • Would everyone who needs to hear the information be present?
  • Would some attendees not need to be present for the report discussion if the meeting had multiple purposes?

Slide 27: Facilitator Role: Piloting Use of Reports

• The team works with Facilitator to develop pilot plan for implementing each report and spreading facilitywide.
• The team typically pilots a report in one unit initially.
• The team pilots additional reports in one unit.
• Once process is finalized, facilities typically implement facilitywide.

Slide 28: Implementation Steps and Timeline

• Created to help nursing homes:
  • Understand practical steps to use the On-Time reports.
  • Help team track progress toward becoming independent in their use of the On-Time reports.
• Timeline:
  • Provides an approximation of how long it will take to completely implement the program.
  • Varies depending on the quality improvement skills of staff and resources available to the facility.

Slide 29: Facilitator Role: Monitoring Implementation Progress

• Throughout the implementation period:
  • Maintain communication with the Change Team as to their progress.
  • Document dates of completion for each implementation step.
  • Note any issues that have affected the facility’s progress.
• Monitor the team’s level of engagement:
  • Are key members of the Change Team participating in meetings regularly?
  • Has there been any significant turnover in staff either on the Change Team or leadership that may affect the team’s functioning?
  • Is the team cohesive? Are team members completing assignments on time?
  • Are there any operational issues, such as reports being unavailable or difficult to print, or meeting space not available, that may affect the program’s progress?
  • Have there been any disruptions to implementation, such as during the annual State survey, followup surveys, and writing of the correction plan, if required?
• If the Facilitator notes any slowing or disruption of the implementation process, work with the program champion to investigate the issues and help devise a plan to address them.

Slide 30: Facilitator Role: Monitoring Impact of On-Time

• Assist the Change Team in selecting metrics based on existing clinical data.
• Review outcomes with team during implementation period to monitor program’s early impact.

Slide 31: Check Your Understanding

• What are the goals of the On-Time program?
• What are the key components of the On-Time program?
• What is the Facilitator’s role in implementing the program?
• What is the role of program champion?
• How would you respond to questions regarding the accuracy of the reports?
• What is the Facilitator’s role in developing the pilot plan?
• What is the Facilitator’s role in prioritizing progress and impact of the program?
• How is the Menu of Implementation Strategies used in the implementation process?
• What is the Facilitator’s role in helping with the Self-Assessment? Incorporating reports into new meetings?

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